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: