Virginia Regulatory Town Hall
Agency
Department of Behavioral Health and Developmental Services
 
Board
State Board of Behavioral Health and Developmental Services
 
Guidance Document Change: The purpose of this memorandum is to remind DBHDS licensed providers of the requirements and expectations for reporting serious incidents to the DBHDS Office of Licensing, pursuant to 12VAC35-46-1070.C. and 12VAC35-105-160.D.2., including the timeframe for reporting incidents; the process for reporting incidents; the allowable timeframe for adding to, amending, or correcting information reported to the Office of Licensing through the Computerized Human Rights Information System (CHRIS); and to inform providers of the processes that the Office of Licensing will follow for issuing citations, repeat citations and sanctions for violations of serious incident reporting requirements. In addition to ensuring all providers understand the regulatory requirements associated with reporting incidents, the processes outlined in this memo are central to the department’s efforts to address compliance indicators related to serious incident reporting as mandated by the US Department of Justice’s (DOJ) Settlement Agreement with Virginia.
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7/9/20  3:12 pm
Commenter: Holly Rhodenhizer, Lutheran Family Services of Virginia

Serious Incidents
 
  1. 24 Hour Reporting in CHRIS – please consider allowing 2 business days for reporting. Allowing extra time allows agency management to review internal Incident Reports to determine need for reporting.
  2. 48 Hour Follow Up in CHRIS – please consider allowing an additional 2 business days for adding additional information. This is rarely enough time to input accurate information, especially if the incident occurred on a weekend. We are often waiting on lab results, follow up appointments to be scheduled, etc. Example: waiting on results of a COVID test often takes 3 – 5 days, this does not fall under the current reporting timeframes.

  3. Progressive Action for Repeat Citations:

    1. The higher the number of people served in an organization, as well as the complexity of the supports provided, often translates to a higher number of incidents.  Larger providers have a greater likelihood of reaching the maximum threshold of four late reports.  
    2. Sponsored Residential providers differ from Group Home, Day Support, etc. in that they operate as an individual family. SRPs tend to provide first response managing incidents. Depending on the incident, they may be involved in managing the incident and not have time to go through the reporting protocols within the time allotted.
    3. Progressive action may result in less reporting as providers will fear for their license if they report late. It may also lead to over reporting as on call managers do not have the option of reviewing incidents with other supervisory staff to make more sound reporting decisions.
    4. Good providers, who may serve hundreds of people, have the potential to lose their license over late reporting. Is DBHDS prepared to serve those people as providers go out of business?

 

CommentID: 83879