Agency
Department of Behavioral Health and Developmental Services
 
Board
State Board of Behavioral Health and Developmental Services
 
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10/30/19  4:08 pm
Commenter: Alleghany Highlands Community Services

Initial Draft Licensing General Chapter
 
1.  106-20 Definitions

Comprehensive assessment means a comprehensive and written assessment that updates and finalizes the the initial assessment. Comment: The comprehensive assessment is completed for most agency's in same day access. The definition suggests two separate assessments which another assessment may not need to be completed within 1-2 weeks of receiving services. The initial assessment is the comprehensive assessment.

Serious Incident: Level II item #4 needs to clarify a TDO or an unplanned medical hospital admission. Level III item #3 is removed - is this intentional?

Serious Incident 4. An unplanned psychiatric or unplanned medical hospital admission of an individual receiving services other than licensed emergency services: Comment: Need to reconsider the reporting of unplanned psychiatric hospitalizations as this is part of the services provided by CSBs.

Medication error - definition removed: Comment: Does medication errors not have to be reported?

Page 12: substance abuse should be changed to substance use disorder

2.  106-70 Renewals F. Failure to submit a completed renewal application prior to the expiration of the provider's current license shall result in the closure of the license. Comment: Should a grace period or a warning be in place prior to closure of the license?
3.  106-110 Compliance 3. All applicable federal, state or local laws and regulations and all applicable department guidance including: Comment: The guidance documents are not regulations and shouldn't be added to the regulatory requirements.
4.  106-120 Corrective Action Plan Regulation does not specify time frame for Licensing Specialist to return the approved CAP or notify if not approved: Comment: Recommend adding a time frame such as 15 business days.
5.  106-300 Employee Training Required initial training: within 7 business days following an employee or contractor's start date, each employee or contractor responsible for training regarding: CPR & first aid: Comment: Difficult meeting this deadline recommend to state "a person shall not work alone without CPR/FIrst aid certification. Most courses are scheduled and would make within 7 days impossible. 
6.  106-400 Mission Statement Any time there is a change to the mission statement Comment: If the mission statement is updated on the website is this sufficient? If not, who is notified?
7.  106-570 Reporting to the department Recommend change the language to read root cause analysis shall be conducted by the provider within 30 business days. 
8.  106-590 C & D  Needs clarification as to what types of complaints are associated with licensing regulations that are not Human Rights
9. 106-810 Emergency preparedness and response plan The provider shall maintain documentation of collaborative outreach to local emergency officials to include local emergency mangers at least annually: Comment: If CSB is part of a local emergency team with County/Community, what type of documentation is needed? 

 

10.

106-700 Floor plan and building modifications Consider clarification on regarding service modifications (ex. siding on house, exterior painting, counter top replacement, etc.)

CommentID: 76772