Please advise how to manage RCA for patients in acute care inpatient psychiatric units who experience an exacerbation of a chronic medical condition not related to behavioral health diagnosis that are out of the provider’s control resulting in transfer to a medical inpatient units for treatment. Determination of root causes for these patients is multivariate, due to physiologic status of the patient, and out of the scope of practice for provider’s staff. 

The requirement to report these events as a Level II "Unplanned medical hospital admission" is likely to result in the provider exceeding the threshold for of 5 incidents in 30 days in a large multi-unit inpatient psychiatric facility when the hospitalization is beyond the control of the provider.

What are the qualifications of DBHDS staff making the determination that an incident is an individual or provider care concern?