Virginia Regulatory Town Hall
Department of Behavioral Health and Developmental Services
State Board of Behavioral Health and Developmental Services
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10/30/19  5:31 pm
Commenter: Tamara Starnes, BRBH CSB

Comments Draft Regs Pages 46-62

Page 46

Ensure seclusion only be used inpatient or correctional setting. 

  • Clarification requested: does “inpatient” include “residential” Crisis Stabilization Units?  Crisis Stabilization units are sometimes referred to as “inpatient”  however are licensed as “residential”


Page 47

  A Prohibition on Staff Visitors

-Do not understand the intention of this statement.

The check of the employees’ or contractors’ driving record shall occur at the time of employment and annually thereafter.

-Does annually thereafter mean on or before their anniversary date or can this mean at an annual interval determined by the CSB? To check yearly creates financial and administrative burden.


Page 48

 New language on transportation.  Mostly stuff we already doing such as requiring seatbelt use and checking driving records.

  • Requires checking driving record at the time of employment and annually thereafter

This seems like a large administrative and cost burden as we have hundreds of employees.


Risk Management A. Provider shall collect, maintain, and review at least quarterly all serious incidents, including level 1, to include analysis of trends, potential systematic issues or causes, indicated remediation, and documentation of steps taken to mitigate potential for future incidents

-By the definitions included in the draft, "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…”  Requiring Level 1 to have quarterly reviews and analysist of trends, etc does not seem necessary and creates a large manpower burden due to volume. For example, if we take someone to the medical or psych hospital upon their request while we are delivering services, this would warrant a review. Many of these are normal things can arise in the clinical delivery of services daily.


Page 49

Reporting to the department C. 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.

- Request the timeframe being 30 business days of discovery.


Page 50

 Continuation of Risk Management and Quality Improvement:

C. Added clarification that systemic risk assessments need to be conducted at least annually to look at environments, policies, and procedures…

-This section is unclear, testing through competency is unclear. Could an agency make up their own test? If so, it may not be valid, etc. 


Page 51

 7. Notice to individuals receiving services and their authorized representatives of where all individual records will be located;

-Recommend this being “upon request” as clients are inundated with information, I do not recall other doctor/healthcare historically giving me this information.


Page 55

Physical Environment Standards (for center-based services):

Required building temperature range changed from 65-80 degrees F to 68-80 degrees F

                -recommend 65-78, closer to what most homeowners maintain.

Page 56

Requirement that all new locations submit a service modification application at least 45 days before opening.  This is also required for all renovations (not just structural modifications to an existing location)

  • Seems onerous and slows down processes that may need to be made quickly to adjust to changing funding environments. There may be several types of renovations that do not effect services and therefore do not need to make notification, could be outside of scope.


A site specific traffic pattern needs to be submitted for each new service location—to include pick-up and drop-off processes.

                -this seems onerous and most traffic patterns may not be under the control of the provider.

Artificial lights have to be provided by electricity

  • Unsure why this is being specified? Could they be solar? Is the intent to have adequate lighting, or not fire/candles?

Flashlights have to be available for each staff member on the premises between dusk and dawn.

-suggest changing to reflect adequate number of flashlights or backup lighting must be available. To note that each staff must have one available makes it sound like one for each person, which could be much more than needed.


Page 61

 C:  Redundant communication systems with the ability to provide a means of communication during commercial power failure. 

  • My concern is this will require the use of traditional phone lines that are increasingly costly to keep and maintain.  The phone system we have has backup for multiple hours of a power outage.  We also have redundancy with a second internet provider. Most programs also have a wealth of cell phone coverage.

 Page 62

 A: A landline telephone shall be accessible for emergency purposes.  The telephone shall be a line capable of operating during a power outage. 

  • My concern is this will require the use of traditional phone lines that are increasingly costly to keep and maintain.  The phone system we have has backup for multiple hours of a power outage.  Many workers have cell phones.



CommentID: 76794