Virginia Regulatory Town Hall
Agency
Department of Behavioral Health and Developmental Services
 
Board
State Board of Behavioral Health and Developmental Services
 
Guidance Document Change: Changes are made to this guidance document to reflect the final, permanent amendments in Action 5040 Compliance with Virginia’s Settlement Agreement with US DOJ, and documents recently published by the department related to those regulatory changes.

10 comments

All comments for this forum
Back to List of Comments
9/28/20  4:30 pm
Commenter: Dan Jenkins

Serious Incident Guidance
 

12VAC35-105-20- under the guidance for Level III Serious Incidents involving sexual assault it states:  

"If the alleged sexual assault does not occur in the provision of a service or on the provider’s premises, reporting of the alleged sexual assault to DBHDS is required only if the adult with capacity gives consent for the report to be made."

Is there an expectation by the department to ask the individual to consent to CHRIS reporting if that individual is an adult with capacity and they disclose a sexual assault to a mental health clinician, case manager, etc. that did not occur on the premises of the provider or during the provision of a service? 

 

Under the same guidance for Level III Serious Incidents involving suicide attempts that result in hospitalization it states:

"Self-injurious behavior without the intent to die that results in a hospital admission or emergency room visit does not need to be reported as a Level III serious incident by all providers. However, the incident must be reported as a Level II serious incident by a provider if the incident occurred within the provision of their services or on their property."

This implies that all instances of self-injury require CHRIS reporting if it occurs on the premises of the provider or during the provision of a service.  It would be understandable to report self-injury if it results in a serious injury, but this language would include a multitude of minor self-inflicted injuries that would not meet the regulatory definition of a serious injury.  Please clarify as the language in its current form would necessitate many more CHRIS reports than what is likely being reported.

 

12VAC35-105-160 E- Providers are no longer required to complete a Root Cause Analysis if the Level III incident did not occur during the provision of a service or on the provider's premises.  However, the proposed guidance document under 12VAC35-105-160 E(1) states:

"In the case of a Level III incident that did not occur while the individual was receiving active services from the provider, or on the provider’s premises, this documentation should include as much information as was reported to, or is otherwise known by the provider."

I think this was just an oversight but I wanted to make sure.  A provider would include this information in a CHRIS report, but not a Root Cause Analysis, because the Root Cause Analysis would not be required for a Level III incident that did not occur during the provision of a service or on the provider's premises.  

In addition, the very last page within the Guidance box states:

"The provider’s serious incident management policy should address how the provider will:
*  Collect, maintain, and review Level I serious incidents at least quarterly;"

Considering the newest regulation requires that providers collect/maintain/review all levels of serious incidents, would it be more helpful if this section of the guidance reflected "all serious incidents," to ensure there are no questions about which incident levels have quarterly reviews?

 

Finally, there are several references to an individual "only receiving licensed emergency services," but it is unclear for a CSB setting if this means the individual's only connection to the provider is through that emergency services program or if this means that the individual could be admitted to other services (like psychosocial rehabilitation or case management) but during the time of the incident, they are only receiving emergency services and those other service providers were not otherwise involved.  Please clarify.

 

CommentID: 86799
 

10/12/20  1:59 pm
Commenter: Jennifer Fidura, Virginia Network of Private Providers

Guidance for Serious Incident Reporting
 

Given that the Department maintains it's threatening posture as outlined in the Guidance Document on Incident Reporting  (22 August, 2020) for failure to timely report; it is critical that the expectations which appear to exceed the regulations be clearly understood. 

The definition of a "Level II" incident is "a serious incident that occurs or originates during the provision of a service or on the premises of the provider."  The "guidance" expands that definition for a class of providers who provide residential service based on the assumption that 24 hour "support" includes exclusive services provision.  The second sentence of that definition is, "Residential services provide a range of living arrangements from highly structured and intensively supervised to relatively independent requiring a modest amount of staff support and monitoring."  The expectation that a residential provider is responsible to "verify" that another licensed provider has reported appropriately a Level II incident which occurred while they were providing service is both outside of their role and responsibility and requires an statement of fact that can not, by the provider, be verified. 

I note that you do not include in your guidance any reference to the responsibility for reporting any incident which may have occurred while with family for the weekend, or while in the hospital.  A trip to the store, part of the Support Plan, and therefore part of the service would seem to fall under the category of "during the provision of service." If the incident does not occur during the provision of services or on the provider's premises, there can not be any obligation/responsibility for reporting.

 

CommentID: 87356
 

10/15/20  10:25 am
Commenter: Rebecca Cash, Valley Community Services Board

Serious Incident Guidance Requests for Clarification
 

12VAC35-105-20

“Level II serious incidents include:….

3. An emergency room visit.

Guidance states “All emergency room visits shall be reported as Level II serious incidents.”

Please clarify if emergency room visits for the sole purpose of accessing psychiatric care (no medical needs or concerns) are required to be reported? There appears to be some discrepancy in interpretation as unplanned psychiatric admissions during the provision of service are required to be reported. Many clients access emergency psychiatric care through the local emergency department, but are not necessarily admitted.  Ex: If a case manager advises individual with crisis symptoms to access local emergency department and individual is not admitted to psychiatric facility but is released on safety plan, is this required to be reported on CHRIS as Level II?

 

4. An unplanned psychiatric admission of an individual receiving services other than licensed emergency services, except that a psychiatric admission in accordance with the individual’s Wellness Recovery Action Plan (WRAP) shall not constitute an unplanned admission for the purposes of this Chapter;

Guidance states “If an individual is admitted to the hospital for psychiatric services, and the individual’s admission is in accordance with the individual’s Wellness Recovery Action Plan (WRAP), then the admission is not an unplanned admission and does not need to be reported.

Please clarify the definition of an “unplanned psychiatric admission” versus a “planned psychiatric admission”? Are voluntary psychiatric admissions considered a planned psychiatric admission and therefore, do not require reporting?  

Thank you for the addition of exceptions related to WRAP. Official WRAP facilitation and implementation can be an expensive and a time-consuming process. Many CSBs have alternate versions of WRAP plans. Is there any flexibility if other crisis plan tools are in place or is a psychiatric admission in accordance with specifically WRAP the only acceptable exception?

CommentID: 87372
 

10/26/20  2:52 pm
Commenter: john humphreys

Residential Provider duties
 

The proposed guidance for serious incident reporting creates an unwarranted, impossible and burdensome requirement for residential providers by creating a duty for residential providers to report level II serious incidents which did not occur during the provision of service or on the provider’s property; that can only be removed “if the provider verifies that the other provider reported the incident”.

  1. This provision is unwarranted duty as it represents an attempt to change the role of the residential provider from providing their licensed services to that of policing agent for the state; a role we do not want, should not have and that would have a corrosive effect on the collaborative provision of supports across providers.
  2. This provision places an impossible duty upon the residential provider because the state has failed to provide mechanisms which would allow the duty to be accomplished.
  • No awareness – This provision assumes that the residential provider will be aware of the level II serious incident at the individual served experienced while receiving services from another provider; however: 1st there is no regulatory requirement that the other provider inform the residential provider of the existence of a level II serious incident impacting the individual they both serve. 2nd A number of level II serious incidents may have no ongoing impact (choking with physical assistance, ingestion of substances, peer to peer incident with potential to harm but no actual harm) which would make it impossible for the residential provider to divine occurrence of the incident and that the individual may decline and/or be incapable of reporting to the residential provider. As currently written a level II serious incident that occurred while the individual was with another provider that the residential provider was never aware of would result in a violation for the residential provider for failure to report if it were discovered at a later date.
  • No mechanism – this provision creates a duty for the residential provider to “verify” (investigation that establishes as fact) that the other provider entered a level II serious incident report; however, the state does not currently provide access to the only mechanism that can be used to accomplish this requirement. Specifically, the only way to “verify” that a level II serious incident report has been entered by the other provider is to view that report in the CHRIS system, but the system is currently constructed does not allow residential providers to view the reports entered by other providers; thus, there is no way to meet the requirement has written. Again, as currently written if a residential provider took the verbal word of another provider that they would file a report, but then did not it would result in a violation for the residential provider for failure to report if it were discovered at a later date.
  • 24 hour reporting – this provision creates no exclusion for the residential provider from the 24 hour requirement if the residential provider were required to enter a level II serious incident report into the CHRIS system, due to the failure of the other provider to make the appropriate entry; given the possible lack of or at the very least guaranteed delayed awareness of the incident and the additional delays created by an attempted verification investigation (closed for the day, relevant staff not available, no answers/declined to comment etc.) it becomes probable that on many occasions the residential provider will not be able to meet the 24 hour standard which would result in a violation for the residential provider due to factors outside their control and despite their due diligence.

     

    3. Onerous burden – this represent yet another example of an unfunded mandate being foisted upon the residential provider (investigation, documentation, reporting) and provides a basis for citing the residential provider for a violation when the residential provider has absolutely 0 control over the circumstances that created the violation and no way to prevent the violation from occurring or reoccurring – beyond unfair to a true injustice.

     

    Recommendations: 1 – remove the requirement in its entirety from the guidance document;

    2 – shift the requirement to the support coordinator, this is much more appropriate to their established role as the state already uses them as a policing agent and their primary responsibility is being aware of and coordinating across services; at the very least 3 – change the duty of the residential provider from verify to confirmation of the intent of the other provider to make the CHRIS entry and exclude the residential provider from the 24 hour requirement in this circumstance.

 

CommentID: 87385
 

10/27/20  5:01 pm
Commenter: Joanna Wise Barnes, ServiceSource, Inc.

Guidance document on serious incident reporting
 

Page 3, #3 – In a recent OL training session on Licensing Regulations/Final DOJ Regs/October 2020, it was clarified that if 911 is called and EMTs recommend transport to the ER, but the individual or SDM declines to go to the ER, UC, or to see a physician, then the incident is not a Level II and a CHRIS report is not required.  We request that this clarification be added to the guidance document. 

 

This is general comment indirectly related to this guidance document.  There are two sides of CHRIS – a Licensing side and a Human Rights side.  Sometimes a report is required on the OL side, sometimes on the OHR side, and sometimes the same report must be entered separately in both sides of CHRIS.  OL has issued this guidance document and conducts almost-monthly on-line training sessions (that historically and routinely have technical difficulties prohibiting full provider participation).  OHR has no guidance document and conducts periodic in-person regional trainings (or did prior to the pandemic).  Requests:

  • OL and OHR work to reprogram CHRIS so that no incident must be entered twice but is visible on both sides when a selection is made for that option.
  • OL and OHR collaborate to produce one guidance document which defines requirements for both sides of CHRIS and addresses requirements for reporting in each and in both sides.
  • OL and OHR collaborate to produce joint trainings to cover reporting on both sides of CHRIS.
  • DBHDS resolve the technical difficulties that have plagued on-line CHRIS trainings for many months without resolution, and which routinely impact other DBHDS staff’s on-line trainings and presentations as well.  Note that OL recently changed to a Zoom platform for its latest CHRIS training, but technical difficulties arose then too. 
CommentID: 87391
 

10/27/20  9:30 pm
Commenter: Karen Tefelski - vaACCSES

Comments - Guidance on Serious Incident Reporting
 

Public Comment -
Guidance for Serious Incident Reporting

Document ID:  LIC 17

 

Overall General Comment: 

This is general comment indirectly related to this guidance document.  There are two sides of CHRIS – a Licensing side and a Human Rights side.  Sometimes a report is required on the OL side, sometimes on the OHR side, and sometimes the same report must be entered separately in both sides of CHRIS.  OL has issued this guidance document and conducts almost-monthly on-line training sessions (that historically and routinely have technical difficulties prohibiting full provider participation).  OHR has no guidance document and conducts periodic in-person regional trainings.  Requests:

  • OL and OHR work to reprogram CHRIS so that no incident must be entered twice but is visible on both sides when a selection is made for that option.
  • OL and OHR collaborate to produce one guidance document which defines requirements for both sides of CHRIS and addresses requirements for reporting in each and in both sides.
  • OL and OHR collaborate to produce joint trainings to cover reporting on both sides of CHRIS.
  • DBHDS resolve the technical difficulties that have plagued on-line CHRIS trainings for many months without resolution, and which routinely impact other DBHDS staff’s on-line trainings and presentations as well.  Note that OL recently changed to a Zoom platform for its latest CHRIS training, but technical difficulties arose then too. 

 

12VAC35-105-20 - Definitions

Page 3 - “Level II serious incidents”

#3 – An emergency room or urgent care facility visit when not used in lieu of a primary care physician visit:
In a recent OL training session on Licensing Regulations/Final DOJ Regs/October 2020, it was clarified that if 911 is called and EMTs recommend transport to the ER, but the individual or SDM declines to go to the ER, UC, or to see a physician, then the incident is not a Level II and a CHRIS report is not required.  We request that this clarification be added to the guidance document. 

 

12VAC35-105-160.E
Page 9 - 160.E (i) Is this an oversight? Regulation states that providers are no longer required to complete a Root Cause Analysis if the Level III incident did not occur during the provision of a service or on the provider’s premises.  However, the proposed guidance document in 12VAC35-105-160.E (i) states: “In the case of a Level III incident that did not occur while the individual was receiving active services from the provider, or on the provider’s premises, this documentation should include as much information as was reported to, or is otherwise known by the provider.”

A provider would include this information in a CHRIS report but not a Root Cause Analysis according to the regulations.

 

Agree with Comment posted by Jennifer Fidura, VNPP

The expectations of the Guidance Document on Serious Incident Reporting appear to exceed the regulations.

“The definition of a "Level II" incident is "a serious incident that occurs or originates during the provision of a service or on the premises of the provider."  The "guidance" expands that definition for a class of providers who provide residential service based on the assumption that 24 hour "support" includes exclusive services provision.  The second sentence of that definition is, "Residential services provide a range of living arrangements from highly structured and intensively supervised to relatively independent requiring a modest amount of staff support and monitoring."  The expectation that a residential provider is responsible to "verify" that another licensed provider has reported appropriately a Level II incident which occurred while they were providing service is both outside of their role and responsibility and requires an statement of fact that can not, by the provider, be verified. 

I note that you do not include in your guidance any reference to the responsibility for reporting any incident which may have occurred while with family for the weekend, or while in the hospital.  A trip to the store, part of the Support Plan, and therefore part of the service would seem to fall under the category of "during the provision of service." If the incident does not occur during the provision of services or on the provider's premises, there can not be any obligation/responsibility for reporting."

CommentID: 87393
 

10/27/20  10:30 pm
Commenter: Every Citizen Has Opportunities, Inc. (ECHO)

Serious Incident Reporting Guidance Document
 

ECHO agrees with the comments below by Karen Tefelski and Jennifer Fidura.

Overall General Comment: 

This is general comment indirectly related to this guidance document.  There are two sides of CHRIS – a Licensing side and a Human Rights side.  Sometimes a report is required on the OL side, sometimes on the OHR side, and sometimes the same report must be entered separately in both sides of CHRIS.  OL has issued this guidance document and conducts almost-monthly on-line training sessions (that historically and routinely have technical difficulties prohibiting full provider participation).  OHR has no guidance document and conducts periodic in-person regional trainings.  Requests:

  • OL and OHR work to reprogram CHRIS so that no incident must be entered twice but is visible on both sides when a selection is made for that option.
  • OL and OHR collaborate to produce one guidance document which defines requirements for both sides of CHRIS and addresses requirements for reporting in each and in both sides.
  • OL and OHR collaborate to produce joint trainings to cover reporting on both sides of CHRIS.

12VAC35-105-20 - Definitions

Page 3 - “Level II serious incidents”

#3 – An emergency room or urgent care facility visit when not used in lieu of a primary care physician visit:
In a recent OL training session on Licensing Regulations/Final DOJ Regs/October 2020, it was clarified that if 911 is called and EMTs recommend transport to the ER, but the individual or SDM declines to go to the ER, UC, or to see a physician, then the incident is not a Level II and a CHRIS report is not required.  We request that this clarification be added to the guidance document. 

 

12VAC35-105-160.E
Page 9 - 160.E (i) Is this an oversight? Regulation states that providers are no longer required to complete a Root Cause Analysis if the Level III incident did not occur during the provision of a service or on the provider’s premises.  However, the proposed guidance document in 12VAC35-105-160.E (i) states: “In the case of a Level III incident that did not occur while the individual was receiving active services from the provider, or on the provider’s premises, this documentation should include as much information as was reported to, or is otherwise known by the provider.”

A provider would include this information in a CHRIS report but not a Root Cause Analysis according to the regulations.

 

Agree with Comment posted by Jennifer Fidura, VNPP

The expectations of the Guidance Document on Serious Incident Reporting appear to exceed the regulations.

“The definition of a "Level II" incident is "a serious incident that occurs or originates during the provision of a service or on the premises of the provider."  The "guidance" expands that definition for a class of providers who provide residential service based on the assumption that 24 hour "support" includes exclusive services provision.  The second sentence of that definition is, "Residential services provide a range of living arrangements from highly structured and intensively supervised to relatively independent requiring a modest amount of staff support and monitoring."  The expectation that a residential provider is responsible to "verify" that another licensed provider has reported appropriately a Level II incident which occurred while they were providing service is both outside of their role and responsibility and requires an statement of fact that can not, by the provider, be verified. 

I note that you do not include in your guidance any reference to the responsibility for reporting any incident which may have occurred while with family for the weekend, or while in the hospital.  A trip to the store, part of the Support Plan, and therefore part of the service would seem to fall under the category of "during the provision of service." If the incident does not occur during the provision of services or on the provider's premises, there can not be any obligation/responsibility for reporting.

CommentID: 87394
 

10/28/20  10:10 am
Commenter: Andie Plumley

Supporting vaACCSES and VNPP Comments
 

Public Comment -
Guidance for Serious Incident Reporting

Document ID:  LIC 17

 

Overall General Comment: 

This is general comment indirectly related to this guidance document.  There are two sides of CHRIS – a Licensing side and a Human Rights side.  Sometimes a report is required on the OL side, sometimes on the OHR side, and sometimes the same report must be entered separately in both sides of CHRIS.  OL has issued this guidance document and conducts almost-monthly on-line training sessions (that historically and routinely have technical difficulties prohibiting full provider participation).  OHR has no guidance document and conducts periodic in-person regional trainings.  Requests:

  • OL and OHR work to reprogram CHRIS so that no incident must be entered twice but is visible on both sides when a selection is made for that option.
  • OL and OHR collaborate to produce one guidance document which defines requirements for both sides of CHRIS and addresses requirements for reporting in each and in both sides.
  • OL and OHR collaborate to produce joint trainings to cover reporting on both sides of CHRIS.
  • DBHDS resolve the technical difficulties that have plagued on-line CHRIS trainings for many months without resolution, and which routinely impact other DBHDS staff’s on-line trainings and presentations as well.  Note that OL recently changed to a Zoom platform for its latest CHRIS training, but technical difficulties arose then too. 

 

12VAC35-105-20 - Definitions

Page 3 - “Level II serious incidents”

#3 – An emergency room or urgent care facility visit when not used in lieu of a primary care physician visit:
In a recent OL training session on Licensing Regulations/Final DOJ Regs/October 2020, it was clarified that if 911 is called and EMTs recommend transport to the ER, but the individual or SDM declines to go to the ER, UC, or to see a physician, then the incident is not a Level II and a CHRIS report is not required.  We request that this clarification be added to the guidance document. 

 

12VAC35-105-160.E
Page 9 - 160.E (i) Is this an oversight? Regulation states that providers are no longer required to complete a Root Cause Analysis if the Level III incident did not occur during the provision of a service or on the provider’s premises.  However, the proposed guidance document in 12VAC35-105-160.E (i) states: “In the case of a Level III incident that did not occur while the individual was receiving active services from the provider, or on the provider’s premises, this documentation should include as much information as was reported to, or is otherwise known by the provider.”

A provider would include this information in a CHRIS report but not a Root Cause Analysis according to the regulations.

 

Agree with Comment posted by Jennifer Fidura, VNPP

The expectations of the Guidance Document on Serious Incident Reporting appear to exceed the regulations.

“The definition of a "Level II" incident is "a serious incident that occurs or originates during the provision of a service or on the premises of the provider."  The "guidance" expands that definition for a class of providers who provide residential service based on the assumption that 24 hour "support" includes exclusive services provision.  The second sentence of that definition is, "Residential services provide a range of living arrangements from highly structured and intensively supervised to relatively independent requiring a modest amount of staff support and monitoring."  The expectation that a residential provider is responsible to "verify" that another licensed provider has reported appropriately a Level II incident which occurred while they were providing service is both outside of their role and responsibility and requires an statement of fact that can not, by the provider, be verified. 

I note that you do not include in your guidance any reference to the responsibility for reporting any incident which may have occurred while with family for the weekend, or while in the hospital.  A trip to the store, part of the Support Plan, and therefore part of the service would seem to fall under the category of "during the provision of service." If the incident does not occur during the provision of services or on the provider's premises, there can not be any obligation/responsibility for reporting."

CommentID: 87396
 

10/28/20  1:54 pm
Commenter: Fairfax-Falls Church CSB

Guidance for Serious Incident Reporting
 

 Guidance for Serious Incident Reporting 

 

12VAC35-105-20- under the guidance for Level III Serious Incidents involving sexual assault it states:  

"If the alleged sexual assault does not occur in the provision of a service or on the provider’s premises, reporting of the alleged sexual assault to DBHDS is required only if the adult with capacity gives consent for the report to be made."

Comments/Feedback: Is there an expectation by the department to ask the individual to consent to CHRIS reporting if that individual is an adult with capacity and they disclose a sexual assault to a mental health clinician, case manager, etc. that did not occur on the premises of the provider or during the provision of a service? 

 A sexual Assault of an Individual  (under Guidance)- A Sexual assault of an individual: “ The Provider must report to DBHDS any alleged sexual assault of a minor or of an adult who is determined to lack capacity pursuant to 12VAC35-115-145.

Comments/ Feedback: How does this work for Youth & Family Services when a youth is in a Psychotherapy session and the youth reports a possible-alleged assault to their Therapist, but the families may not even be aware of the situation/event, and the provider must report  to DBHDS. The families may not even be aware of the report to DBHDS? Does DBHDS inform the families prior to reporting?

Under the same guidance for Level III Serious Incidents involving suicide attempts that result in hospitalization it states:

"Self-injurious behavior without the intent to die that results in a hospital admission or emergency room visit does not need to be reported as a Level III serious incident by all providers. However, the incident must be reported as a Level II serious incident by a provider if the incident occurred within the provision of their services or on their property."

Comments/Feedback: This implies that all instances of self-injury require CHRIS reporting if it occurs on the premises of the provider or during the provision of a service.  It would be understandable to report self-injury if it results in a serious injury, but this language would include a multitude of minor self-inflicted injuries that would not meet the regulatory definition of a serious injury.  Please clarify as the language in its current form would necessitate many more CHRIS reports than what is likely being reported.

The definition of a "Level II" incident is "a serious incident that occurs or originates during the provision of a service or on the premises of the provider."  The "guidance" expands that definition for a class of providers who provide residential service based on the assumption that 24 hour "support" includes exclusive services provision.  The second sentence of that definition is, "Residential services provide a range of living arrangements from highly structured and intensively supervised to relatively independent requiring a modest amount of staff support and monitoring."  The expectation that a residential provider is responsible to "verify" that another licensed provider has reported appropriately a Level II incident which occurred while they were providing service is both outside of their role and responsibility and requires an statement of fact that can not, by the provider, be verified. 

The guidance does not include any reference to the responsibility for reporting any incident which may have occurred while with family for the weekend, or while in the hospital.  A trip to the store, part of the Support Plan, and therefore part of the service would seem to fall under the category of "during the provision of service." If the incident does not occur during the provision of services or on the provider's premises, there cannot be any obligation/responsibility for reporting.

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

12VAC35-105-160 E- Providers are no longer required to complete a Root Cause Analysis if the Level III incident did not occur during the provision of a service or on the provider's premises.  However, the proposed guidance document under 12VAC35-105-160 E (1) states:

"In the case of a Level III incident that did not occur while the individual was receiving active services from the provider, or on the provider’s premises, this documentation should include as much information as was reported to, or is otherwise known by the provider."

Comments/Feedback: is this is an oversight?  A provider would include this information in a CHRIS report, but not a Root Cause Analysis, because the Root Cause Analysis would not be required for a Level III incident that did not occur during the provision of a service or on the provider's premises.  

In addition, the very last page within the Guidance box states:

"The provider’s serious incident management policy should address how the provider will:
* Collect, maintain, and review Level I serious incidents at least quarterly;"

Comments/Feedback: Considering the newest regulation requires that providers collect/maintain/review all levels of serious incidents, would it be more helpful if this section of the guidance reflected "all serious incidents," to ensure there are no questions about which incident levels have quarterly reviews?

12VAC35-105-160 E: “A root cause analysis shall be conducted by the provider within 30 days of discovery of Level II serious incidents and any Level III serious incidents that occur during the provision of a service or on the provider's premises.”

Comments/ Feedback: Clarification on RCAs- specifically around Level 3- Deaths. All deaths should not require an RCA, i.e. A person who is on hospice care or the death is due to the natural progression of disease

Clarification needed:  there are several references in the Guidance  to an individual "only receiving licensed emergency services," but it is unclear for a CSB setting if this means the individual's only connection to the provider is through that emergency services program or if this means that the individual could be admitted to other services (like psychosocial rehabilitation or case management) but during the time of the incident, they are only receiving emergency services and those other service providers were not otherwise involved.  Please clarify.

12VAC35-105-20

“Level II serious incidents include:

3. An emergency room visit.

Guidance states “All emergency room visits shall be reported as Level II serious incidents.”

Comments/Feedback: Please clarify if emergency room visits for the sole purpose of accessing psychiatric care (no medical needs or concerns) are required to be reported? There appears to be some discrepancy in interpretation as unplanned psychiatric admissions during the provision of service are required to be reported. Many clients access emergency psychiatric care through the local emergency department but are not necessarily admitted.  Ex: If a case manager advises individual with crisis symptoms to access local emergency department and individual is not admitted to psychiatric facility but is released on safety plan, is this required to be reported on CHRIS as Level II?

 Need additional Clarification: is ALL ER visits Reported as a Level 2, including those that occur during Emergency Services regular course of business? For example, how about situations where there were no diagnosis, treatments, or patient declines or refuses treatment, or the patient. walks out without being seen. Would these situational events also be classified as an ER visit/Level 2 SIR. In addition, having to report every ER visit will increase the regulatory burden for larger organizations

4. An unplanned psychiatric admission of an individual receiving services other than licensed emergency services, except that a psychiatric admission in accordance with the individual’s Wellness Recovery Action Plan (WRAP) shall not constitute an unplanned admission for the purposes of this Chapter;

Guidance states “If an individual is admitted to the hospital for psychiatric services, and the individual’s admission is in accordance with the individual’s Wellness Recovery Action Plan (WRAP), then the admission is not an unplanned admission and does not need to be reported.

Comments/Feedback: Please clarify the definition of an “unplanned psychiatric admission” versus a “planned psychiatric admission”? Are voluntary psychiatric admissions considered a planned psychiatric admission and therefore, do not require reporting?  

Many CSBs have alternate versions of WRAP plans. Is there any flexibility if other crisis plan tools are in place or is a psychiatric admission in accordance with specifically WRAP the only acceptable exception?

Fairfax- Falls Church CSB is also supporting comments by Karen Tefelski – vaACCSES :

Overall General Comment: 

This is general comment indirectly related to this guidance document.  There are two sides of CHRIS – a Licensing side and a Human Rights side.  Sometimes a report is required on the OL side, sometimes on the OHR side, and sometimes the same report must be entered separately in both sides of CHRIS.  OL has issued this guidance document and conducts almost-monthly on-line training sessions (that historically and routinely have technical difficulties prohibiting full provider participation).  OHR has no guidance document and conducts periodic in-person regional trainings.  Requests:

  • OL and OHR work to reprogram CHRIS so that no incident must be entered twice but is visible on both sides when a selection is made for that option.
  • OL and OHR collaborate to produce one guidance document which defines requirements for both sides of CHRIS and addresses requirements for reporting in each and in both sides.
  • OL and OHR collaborate to produce joint trainings to cover reporting on both sides of CHRIS.
  • DBHDS resolve the technical difficulties that have plagued on-line CHRIS trainings for many months without resolution, and which routinely impact other DBHDS staff’s on-line trainings and presentations as well.  Note that OL recently changed to a Zoom platform for its latest CHRIS training, but technical difficulties arose then too. 

 

 

 

 

 

CommentID: 87399
 

10/28/20  5:14 pm
Commenter: Kim Black, Hope House Foundation

Guidance for Serious Incident Reporting
 

Guidance: Providers are not required to report Level I serious incidents via DBHDS’ web-based reporting application (CHRIS) to the Office of Licensing. Level I serious incidents, by definition, occur or originate during the provision of services or on the premises of the provider. “[D]uring the provision of a service” means that the incident occurs when the provider is actively providing a service to the individual. o For example, if an individual reports to his case manager that the individual fell off of his bicycle at the group home and sustained minor injuries, the case manager is not required to collect, maintain, and review this information as part of the quality improvement program, although this information may be pertinent to the case manager’s responsibilities under 12VAC35-105-1245. The DBHDS-licensed group home provider, however, is required to collect, maintain, and review this information as part of its quality improvement program (discussed further below).

Comment: If someone receiving in-home services goes to the ER independently would that be reportable? Using the guidance above, the in-home service provider would not be required to report as a Level 2 incident as there was no provision of service. Another example: If someone receiving in-home services is diagnosed with a decubitus ulcer while attending a doctor’s appointment with their parents, the in-home service provider would not be required to report as a Level 2 incident as there was no provision of service. It seems like the intent of the regulation is for DBHDS to know about the ER visit and the ulcer but for an in-home provider only events that occur when a staff is present would be reportable.

Guidance: Providers licensed to provide a “residential service” as defined by 12VAC35-105-20 provide 24-hour support to individuals. However, if an individual receiving residential services experiences a Level II serious incident while actively receiving services from another licensed provider, the residential service provider is not required to report the incident if the provider verifies that the other provider reported the incident

Comment: Not all residential services are provided 24 hours a day. Some individuals receive as little as 4 hours per week. The burden of reporting incidents that occur during the other 164 hours in the week should not fall on the provider.

Regulation: "Level II serious incident" includes a significant harm or threat to the health or safety of others caused by an individual.

Comment: Does this mean that if person in services #1 threatens harm to person in services #2 during the provision of service, that this is a reportable event? Is a provider reporting a threat to harm that does not result in any injury?

Guidance: Providers licensed to provide a “residential service” as defined by 12VAC35-105-20 provide 24-hour support to individuals. However, if an individual receiving residential services experiences a Level II serious incident while actively receiving services from another licensed provider, the residential service provider is not required to report the incident if the provider verifies that the other provider reported the incident. For example, if an individual who receives group home services sustains a serious injury at a day support program, the group home provider is not required to report the serious injury as long as the group home provider verifies that the day support provider reported the incident. However, if an individual receiving services from a residential service provider sustains a serious injury during an independent trip to the grocery store, the residential service provider must report the serious injury as a Level II serious incident.

Comment: If the above guidance is to be used, then ‘during the provision of service’ has no meaning to in-home providers. We are the default for reporting all incidents even when they occur outside of the provision of service.

Regulation: "Level II serious incidents" include:

Guidance: Please note that per Code of Virginia § 1-218 the term “includes” means “includes, but not limited to.” Therefore, Level II serious incidents are not limited to the incidents enumerated below.

Comment: The list is not exhaustive and allows for the discretion of interpretation of licensing specialists. This is not helpful for providers building policy and procedure to ensure thorough training of staff.

Guidance: DBHDS regulation 12VAC35-105-20 defines a “suicide attempt” as “a nonfatal, self-directed, potentially injurious behavior with an intent to die as a result of the behavior regardless of whether it results in injury.” If an individual admitted for services is admitted to the hospital as a result of self-directed behavior, and it is determined by a licensed professional that the individual intended to die as a result of the behavior, all providers are required to report this incident as a Level III serious incident regardless of whether the incident occurred within the provision of their services or on their property.

Comment: Is it accurate that if the provider asks the individual, “Did you intend to die?” and the answer is “No”, then the provider does not have to report this incident as a Level 3?

Regulation: Level II and Level III serious incidents shall be reported using the department's web based reporting application and by telephone or email to anyone designated by the individual to receive such notice and to the individual's authorized representative within 24 hours of discovery. Reported information shall include the information specified by the department as required in its web-based reporting application, but at least the following: the date, place, and circumstances of the serious incident. For serious injuries and deaths, the reported information shall also include the nature of the individual's injuries or circumstances of the death and any treatment received. For all other Level II and Level III serious incidents, the reported information shall also include the consequences that resulted from the serious incident. Deaths that occur in a hospital as a result of illness or injury occurring when the individual was in a licensed service shall be reported.

Comments: An example of consequences would be helpful to include.

General Comments:

Hope House Foundation also agrees with comment posted by Jennifer Fidura, VNPP

The expectations of the Guidance Document on Serious Incident Reporting appear to exceed the regulations.

“The definition of a "Level II" incident is "a serious incident that occurs or originates during the provision of a service or on the premises of the provider."  The "guidance" expands that definition for a class of providers who provide residential service based on the assumption that 24 hour "support" includes exclusive services provision.  The second sentence of that definition is, "Residential services provide a range of living arrangements from highly structured and intensively supervised to relatively independent requiring a modest amount of staff support and monitoring."  The expectation that a residential provider is responsible to "verify" that another licensed provider has reported appropriately a Level II incident which occurred while they were providing service is both outside of their role and responsibility and requires an statement of fact that can not, by the provider, be verified. 

I note that you do not include in your guidance any reference to the responsibility for reporting any incident which may have occurred while with family for the weekend, or while in the hospital.  A trip to the store, part of the Support Plan, and therefore part of the service would seem to fall under the category of "during the provision of service." If the incident does not occur during the provision of services or on the provider's premises, there can not be any obligation/responsibility for reporting."

Hope House Foundation also supporting comments by Karen Tefelski – vaACCSES :

This is general comment indirectly related to this guidance document.  There are two sides of CHRIS – a Licensing side and a Human Rights side.  Sometimes a report is required on the OL side, sometimes on the OHR side, and sometimes the same report must be entered separately in both sides of CHRIS.  OL has issued this guidance document and conducts almost-monthly on-line training sessions (that historically and routinely have technical difficulties prohibiting full provider participation).  OHR has no guidance document and conducts periodic in-person regional trainings.  Requests:

  • OL and OHR work to reprogram CHRIS so that no incident must be entered twice but is visible on both sides when a selection is made for that option.
  • OL and OHR collaborate to produce one guidance document which defines requirements for both sides of CHRIS and addresses requirements for reporting in each and in both sides.
  • OL and OHR collaborate to produce joint trainings to cover reporting on both sides of CHRIS.
  • DBHDS resolve the technical difficulties that have plagued on-line CHRIS trainings for many months without resolution, and which routinely impact other DBHDS staff’s on-line trainings and presentations as well.  Note that OL recently changed to a Zoom platform for its latest CHRIS training, but technical difficulties arose then too. 

Hope House Foundation agrees with the comment made by Fairfax-Falls Church CSB: The expectation that a residential provider is responsible to "verify" that another licensed provider has reported appropriately a Level II incident which occurred while they were providing service is both outside of their role and responsibility and requires an statement of fact that cannot, by the provider, be verified. 

CommentID: 87401