The draft guidance document refers to the date of June 15, 2020 for repeat citations, is this date confirmed since the guidance document is under public comment period?

When does the 2 year period begin for repeat citations? 

This "4-strikes and you're out" policy designed by DBHDS is absurd.  As defined by this document, the guidance is not only impossible to fairly implement across the various sizes and scopes of services and organizations across the state, it's now further prioritizing an arbitrary time-sensitive reporting requirement over the quality service provision that happens during all the other moments not defined by a "level."  

How is it justifiable to give a small provider the same number of "strikes" as a larger provider?  If one outpatient clinic in a region with a large population serves 2000 clients in a year, but another one in a rural community serves 100, how is it fair that both have the same number of strikes when one of them has a much higher risk of incident simply because they support more people?

Same question, different service... How about case management services for people with substance use disorders?  Different CSBs have varying numbers of clients and therefore different numbers of case managers.  That means the level of probability for an incident to take place varies across CSBs.  But by the guidance outlined in this document, they each have the exact same number of strikes before their ability to perform the service will be taken away by the department.  

As a Risk Management Specialist working in compliance, I can certainly understand how unbelievably frustrating it is when people don't follow the rules.  Regulations, policies, procedures, guidance documents... those are the pages of the rule book and they outline the way it should be and what could happen if it isn't that way.  

But ultimately, those consequences must be in line with the severity of the infraction.  And realistically, submitting a CHRIS report sometime after 24 hours just isn't that severe when you realize that no one from DBHDS is going to read it before 8am or after 5pm on any given Monday through Friday.  Nor will they read the report on Saturday, Sunday or any recognized holiday.  

Enforcing a consequence for not following the rules is understandable and necessary... but threatening to end an essential service to the community because a report was late only 4 times in 2 years (rolling, calendar, fiscal, who knows?) is an indefensible position.  

Failing to report an incident is far different and far more concerning than late-reporting.  The first indicates either a deliberate attempt to hide an incident or (much more likely) a general and possibly systemic misunderstanding of what constitutes an incident. 

The second indicates that someone or a group of someones forgot, but something was in place to make sure it got reported anyway, regardless of consequences from the department for being late.  

And yet, this guidance document draws no such distinction.  The same citation schedule is implemented for both infractions and the deliberate or unintentional non-reporting is rewarded because that's only get to "caught" if there's an audit.  

Therefore, what would be the motivation for a provider to report an incident after the 24th hour at all?  According to this guidance document it's a guaranteed threat to their license at that point, while only a possible threat (of equal severity) to their license if it is discovered during a site visit, etc.?  

The providers that have frustrated the department by reporting late (the providers that this guidance document is clearly targeting) will simply stop reporting late.  They might try to implement the various vague risk management strategies outlined in the CAP process, but eventually they're going to decide to stop reporting incidents after the 24th hour.  The incidents will still happen of course, but the department won't find out unless they discover it during an audit.  

That's horrifying.  And this guidance document is encouraging it.  

The rest of the providers, the ones who stubbornly insist on ethical behavior, will get caught in the trap.  And those providers will spend even more time and money, not supporting people in need, but attempting to revise or develop more administrative policy and procedures (with ongoing monitoring... whatever that means) to eliminate the ever-present human error factor that goes into 1.) deciphering what constitutes an incident or injury or both, 2.) what "level" that falls into and 3.) how to make sure somebody gave the department a reason to further scrutinize and threaten them within 24 hours of it all happening.  

Please reconsider this guidance document in its entirety.  It's hard enough to find, hire and train qualified professionals willing to perform all the different services necessary to support our communities living with mental health disorders, substance use disorders and developmental disabilities. 

It's going to be even harder when they have to do that work under the constant threat of license revocation for having the audacity to support a person through an incident but forgetting to tell the department in time.  

Keeping in mind that Guidance Documents are interpretive of regulations and while they may bind regulators who are obligated to adhere to regulations, they do not bind the regulated entities.  Therefore:

• As the only “acceptable” method of reporting a serious incident or an allegation of abuse or neglect is the department’s web-based system (CHRIS); the threat of citation for any report outside the limited 24 hour time frame is unreasonable.  This is especially true because the only alternative method (email) is allowable only if the CHRIS portal is determined to be unavailable or another reason “not under the provider’s control.” There are a myriad of reasons why communication option(s) dependent on technology (up to and including a source of power) may be unavailable and, absent confidence that “not under the provider’s control” will be based on the judgement of the provider this is obviously problematic.  This Guidance might be manageable if there were DBHDS/DELTA support staff available 24/7 via telephonic means.
• Lacking 24/7 support, the insistence in the Guidance, under threat of citation, that providers must have sufficient authorized users to allow for incidents to be entered 24/7 is also unreasonable.  There are a myriad of reasons why an authorized user could not access the system or that even with multiple authorized users none would be available on a timely manner to do so.  It should be noted that the first duty for the provider is care not entering data in the DBHDS data bank.

For these two items – the issue is not to dispute the requirement for reporting within 24 hours, the issue is the interpretation (and apparent current practice) that the citation is to be issued based solely on the timestamp on the report  (data not available to the provider in the printed report); it is therefore, without any consideration of mitigating circumstance.  

Serious incidents may also be considered issues of possible abuse or neglect.  Therefore:

• Either the provider will make that determination and file both a serious incident report AND an allegation of abuse or neglect report for the same occurrence, OR the staff of the Incident Management Unit (IMU) will determine that, in their opinion, the incident warrants an investigation of possible abuse or neglect and will note that the provider has not filed on the OHR side of CHRIS.
• Allegations made by IMU must be communicated to the provider directly including the name of the individual making the allegation and the specific allegation.  The provider, who should note those details, can then initiate their internal process for complying with 12VAC35-115-230.  Making an assumption that this should have been done by the provider and communicating directly with staff of OHR should be viewed as negligence on the part of the IMU staff and treated accordingly.
• The issuance of a citation for late report by OHR without determination that the provider had been informed of an allegation of abuse or neglect (apparent current practice) is in itself an “abuse” of the regulatory authority.

12VAC35-105-160F is the generic provision that covers DBHDS’s right to ask and the provider’s responsibility to provide information:

• “D. F. The provider shall submit, or make available and, when requested, submit reports and information that the department requires to establish compliance with these regulations and applicable statutes.”   

• Requiring, under threat of citation for any violation, “follow-up” within a 48 hour time frame reinforces the perception that this Guidance is not designed to improve the quality of the services provided, but is instead designed to improve the data available to show to the Independent Reviewer for the DOJ Settlement Agreement – whether the data is of any value or not!
• There are any number of reasons why follow-up details and information may not be available within 48 hours – results of lab work not yet available to make a conclusive diagnosis,  or inability to discuss incident in more detail with staff who may not be on duty, are two that come quickly to mind.  If the provider adheres to the required timeframe, information will be inaccurate, incomplete or both. 
• If the request for follow-up is made by the IMU, they must be required to request the information in writing (via email) with a notation of when the email was read as the time to note for when the clock starts ticking! Entries in the CHRIS system are insufficient as a tool to communicate as there is not any reason why the provider should take the time to review the entries made by IMU, OL or OHR staff.

On the last issue of progressive discipline toward termination (and this ties directly to the concerns which will be noted separately about the new proposed language in 12VAC35-105-170H and the related Guidance), the threat of refusing to renew a license, to issue a provisional license or to revoke or suspend a license at the forth citation because the provider failed on three occasions to implement an adequate corrective action plan to “prevent recurrence” speaks directly to the earlier comment.  None of this “Guidance” is intended to improve the quality of the care or services, but to impress the Independent Reviewer for the DOJ Settlement Agreement that DBHDS can be very tough on its provider community.

Actions under §37.2-415 and §37.2-418 are appealable under the  Administrative Process Act (§ 2.2-4000 et seq.) and, therefore, should require a level of significant or serious concern, e.g., the health or welfare of the individuals  served.  Admittedly, with the system to be in place when the Guidance documents currently under review are fully implemented the first failure to report will result in a citation of 12VAC35-105-160 (unless of course there is follow-up submitted more than 48 hours after first report and then there will be two citations); for the second failure, there will be a citation as above, plus a citation of 12VAC35-105-170H for failure to implement the CAP which had to have said that the provider would “prevent recurrence;” for the third failure, there will be the same and DMAS will be notified.  At the fourth failure, the provider will be receiving their sixth and seventh citations for 160 and 170 and failure to “prevent recurrence.”  It becomes quickly an untenable position for the provider as failure to comply with the timeframes set is not always preventable and adds nothing to the value of the services provided.

For a large provider, this will be an ongoing battle – we strongly object to the Guidance being provided especially since the data suggest that currently there is approximately 90% compliance with the reporting timeframe.

In response to the proposed serious incident guidance, we wish to convey the following concerns and or considerations:

• Since the IMU service has not rolled out to all regions perhaps this should be delayed until such time that DBHDS is able to uniformly hold every provider to expectations.  Larger providers may serve several regions and keeping programs in congruence becomes increasingly difficult with the differing needs from DBHDS.
• Office of Human Rights and Office of Licensing have two separate timelines for CHRIS report entry.  Because a serious incident report requires the number of the Human Rights report, there is a possible confusion or breakdown.  Since no one responds to serious incident reports that are entered over weekends or holidays, perhaps it should be considered appropriate to adjust the Office of Licensing’s timeline to match that of the Office of Human Rights and require that all reports are entered in CHRIS on the next business day.  This will allow providers to focus more on addressing the incident rather than ensuring time is made for paperwork, which can be completed on the next business day without issue.  The guidance clearly states that the IMU pulls reports on business days – providers should have the same courtesy.
• The expectation that CHRIS reports will be updated within 48 hours is unreasonable.  There are times when 48 hours pass and the additional information needed is not yet available.  This creates additional burden on the provider to go in and indicate that no further updates are available yet.  One example of this is entering COVID-19 test results which can take up to 5 days to receive once the individual is able to be tested.
• The IMU has not been consistently following the protocols for reaching out to providers with questions – recently we’ve had reports issued without engaging with us.  One such report was generated because of a clerical error that we could have resolved very quickly.
• Providers should be alerted annually to the contact lists held in DBHDS systems to ensure that they are consistently updated. 
• Progressive Action for Repeat Citations should not be in effect as of June 15^th, since the review of the document is not yet complete.  This should not go into effect until the document has had a fair review and providers of varying sizes should be included in this review. The information was sent out on June 3rd, a 12 calendar day (7 business day) period is insufficient to prepare providers for such a significant change that threatens their license renewals or applications.
• The inconsistency with which licensing agents address situations and issue citations will need to be addressed.  This has long been a concern of many providers.  Larger providers bear the brunt of this inconsistency, as well, due to needing to work with, possibly, several different licensing agents who all focus in on different things and interprets the regulations differently.  We’ve been told by licensing that this is not the case – but it is; if you look at the larger providers that traverse several regions, you will find that some have citations for the same things over and over and others do not review that portion of the regulations. 

Provider has concerns in regards to receiving a CAP if, in the event of not being able to access the CHRIS system for reasons that were not in the provider’s control, does it not seem logical that the same provider may not be able to email the IMU within 24 hours either?  This provider’s agency is relatively small, with staff living in the same geographic area.  Provider has multiple people designated as able to access CHRIS to report, but should there be a major weather event that disrupted power for several days, this could be an example of a time outside of the provider’s control when it may not be possible to report directly into CHRIS or notify IMU of an incident within 24 hours. 

A “2 year” frame to track citations – what “2 years” is this?  Calendar? Fiscal? Rolling?...

Provider takes issue with the 48 hour time frame to update CHRIS with medical reports or other records.  This information comes from outside the agency, and the provider has no control over how quickly a lab test is run and results received by a doctor and the results passed on to the agency.  There are many instances where this provider could say that 48 hours may not be enough time to update the CHRIS report.  Results of medical treatments may not be known; a missing person is not located; test results not received; PCP follow-up appointments are rarely within 48 hours.  Unless the department’s only goal with this guidance is to issue citations, this section needs to be reviewed more closely to allow greater flexibility to Licensing Specialists and/or IMU to expand on time frames when needed.  A suggestion by this provider would be an update to the CHRIS report within 24 hours of results received, which follows with initial reporting guidelines.  Also, how are providers notified by IMU of requests?  Email?  Providers typically only look at the CHRIS reports when the provider has information to post – they are not sitting checking SIRs waiting for some communication from the Department to appear.  To be frank, providers have too many other irons in the fire to do so, or to pay a staff person to do this.

In the section on CAPs, the proposed CAP should “include systemic actions to ensure future compliance” – Providers cannot guarantee a policy that is reviewed and known by all staff with reporting access will always be followed 100 % of the time.  Providers are staffed by human beings, we do not have the luxury of an “automated system” to designate to determine

1. Is the Person okay???
2. Was this an incident or an injury?
3. What level?
4. Was this in lieu of a doctor’s appointment?
5. What was the medical treatment received?
6. What was the situation when the incident/injury occurred?
7. What are the future risks of harm indicated?

Many (I hope most) providers are dedicated to providing the best care they can, and along with that care is being compliant with reporting guidelines such as reporting within 24 hours of discovery even though these reports are not read over the weekend or holidays or vacations or outside of 9am to 5pm Monday to Friday.  But this revised system, when a provider KNOWS they will receive a citation for reporting at 24 hours and 10 minutes – how does it benefit the provider or the PERSON BEING SERVED???  Or the Department and the data they are tracking?  This provider can certainly see instances, just as another commenter did, when a provider may make a cost/benefit analysis, and roll the dice on NOT REPORTING a UTI diagnosis at an Urgent Care that occurred on Friday evening, which the provider received notification about Saturday afternoon when they checked their email or voice messages, and now have about 3 hours to be compliant with this and they are literally sitting at a wedding for a family member.  That provider may decide to put the phone back in their pocket and see if it is caught in an unscheduled audit.  If the Department is already seeing about 90% compliance with this reporting requirement, these additional threats of citations seem to encourage the idea that DBHDS is openly hostile to providers and want nothing more than to find a way to issue citations.  As another commenter noted, it merely seems to be checking a box for the Department to show to the Independent Reviewer to show how tough the Department is on the provider community.

This Guidance for 160, combined with the Guidance out for comment (but already in effect!) for 170, could easily result in a provider losing their license for a CHRIS SIR report being late by 10 minutes, after already receiving a citation for a report that was only minutes late.  Compare this to a provider who KNOWINGLY does not report less serious incidents for a variety of reasons, would realistically receive ONE CITATION, IF ANY, and only then if this is caught in an audit.

The Guidance document should not be in effect as of June 15^th, since the review of the document is not yet complete.  A Guidance document should not go into effect until the document has had a fair review with providers of varying sizes included. The information was sent out on June 3^rd.  A 12 calendar day, 7 business day, period is insufficient to prepare providers for such a significant change that threatens their license.

This provider would also point out that at the Federal level, regulating via Guidance, which does not have the same scrutiny and process length that Regulations do and is what is happening here, is no longer allowed.

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?

Part of the strength of DBHDS has been an ability to facilitate collaboration with providers, which enables providers to be appropriately responsive across a range of scenarios and services. While we uphold the need for clear regulations and accurate reporting of serious incidents, the proposed changes in the Incident Reporting Requirements Memorandum impede our ability, as a community provider, to meet those expectations and provide effective reporting, and, ultimately, these changes hamper our ability to offer responsive care to those we serve.

“When the provider must update an incident report in CHRIS after the initial submission, the provider must do so within 48 hours from the initial submission of the incident report, or from the time that the provider is informed by the IMU of the need to update the report, whichever is later. Failure to update a serious incident report in CHRIS within 48 hours from the initial submission of the report, or from the time that the provider is informed by the IMU of the need to update the report, will be cited as a regulatory violation of 12VAC35-105-160.F. or 12VAC35-46-230.A., as applicable.” 

• As a community-based provider the requirements of 24- and 48- hour deadlines create significant burden. For this category of provider, reportable incidents occur outside a provider facility often without direct observation. Therefore, our ability to collect accurate and timely information is limited. Even with an additional 24 hours, the ongoing administrative burden to collect, verify, and submit report updates are often limited by delays in testing or access to necessary points of contact, both of which are required to inform accurate reports. Case in point, faced with the sudden death of a client, the threat of citation forces providers to investigate an incident with grieving family members simply to satisfy the reporting requirements rather than offer the flexibility to deliver the courtesy and respect, which should prevail with those we serve, and gather the necessary information in an appropriate manner. 
• This restrictive timeline requires formal communication from IMU, perpetuates a disregard for context, and limits provider ability to implement appropriate situational responses, thus shifting the focus from care to simply avoiding discipline. The proposed punitive response shifts the focus from specific provider improvements or quality of care issues, to a re-focusing on provider efforts to improve CHRIS reporting processes in order to 'beat the clock.’ 

Beginning June 15, 2020, the Office of Licensing will implement progressive citation protocols to address repeat violations of serious incident documentation and reporting requirements.  

What happens when that ‘regulatory violation’ is (or was) a late initial or updated report due to factors beyond provider control?

• The reality of receiving a corrective action plan for a report submitted after the required time period, along with the compounding discipline for issues associated with report detail and timeliness, will fail to create better or even more consistent reporting but quite the opposite. 
• If an individual living in the home reports that a child is not at home because the family has taken them to the hospital, there exists several factors impacting our ability to provide a timely report. First of all, when the information offered at the "point of discovery” is volunteered by individuals who exist outside the protected HIPAA relationship, rights to privacy must be considered and limit the information we are able to gather. Second, if the clinician is unable to immediately access the family to verify the report as well as the status of the child, the ability to reasonably provide an accurate report in 24 hours becomes difficult and possibly unnecessary. In addition, if that clinician is then disciplined for failing to notify their supervisor immediately, despite the lack of confirmed information, their willingness, and soon that of their colleagues, to report future concerns plummets. As a provider, we want our staff to communicate issues, continue to collect information as it is relevant, and respond appropriately in the best interest of the client or family.  
• Collaborative engagement with the licensing specialist at the point of incident or simply allowing for flexibility of the reporting requirements, including the timeline, would serve to foster better alignment between providers and state agencies. Unfortunately, the severity of these requirements creates a punitive relationship that likely opposes the intent of DBHD’s proposed changes. 

"Fourth Citation: When issued related to the reporting of serious incidents, deaths, or allegations of abuse or neglect within a two-year period, in addition to the steps enumerated above for the third citation, the Office of Licensing may do any of the following:

Ø Deny an application for a license or license renewal (Code of Virginia § 37.2-418 and 12VAC35- 105-110 or 12VAC35-46-120);

·       Ø  Issue a provisional license (Code of Virginia § 37.2-415 and 12VAC35-105-50A.2. or 12VAC35- 46-90.B.); or

·       Ø  Revoke or suspend a full, conditional, or provisional license, due to the provider’s repeated failure to submit or implement an adequate CAP (Code of “Virginia § 37.2-418 and 12VAC35- 105-110 or 12VAC35-46-1630). "

• Quantifying citations ignores the size and scope of care programs and adversely impacts larger providers. While repeated violations should be a concern and placed under the consideration of licensing specialists, the language above fails to distinguish any variation in the level of risk specific to providers or programs. The differences between the risk for citations when considering a small BH clinic versus a large, statewide, in-home provider the variation of risk becomes clear, and yet, as it reads, the consequence of citation is applied the same to each regardless. 

While we understand the need for regulations to support ongoing provider improvements and ultimately the safety of those we serve, the regulations as written derail efforts to reinforce positive provider response and, instead, creates a system of punishment more focused on compliance with the reporting system itself than on those it was created to protect. 

• Please provide clarification regarding two year time frame for tracking citations. When does the two years start –effective date of guidance being approved? Is this a rolling two years, fiscal year, calendar year, etc.? 

• If the expectation is for providers to have all reports entered on CHRIS within 24 hours 100% of the time with little allowance for extenuating circumstances per this guidance, then a representative from DBHDS should be available 24/7 to read these reports and be available via phone call if needed to take a report. Access to Internet to complete CHRIS or email IMU is not always available particularly for rural  communities.

• Please consider an agency’s size when having progressive citations due to late reporting. For larger agencies, a percentage may be a more fair, accurate way of identifying systemic issues with late reporting. It seems that it would be more beneficial to both DBHDS, community providers, and the individuals served to truly focus on systemic issues based on patterns and trends of non-compliance.

• The requirement for updates to CHRIS to be entered within 48 hours is very strict. Often times these updates are dependent on obtaining information from external sources (hospital, psychiatric facilities, etc.) which is outside of the provider’s control.

• In regards to progressive citations, please detail the steps that providers can take if issued provisional license to come back in to good standing.

• There are significant concerns that these additional guidance documents are essentially being treated as another set of regulations to be followed. It seems that technical assistance has been replaced with citations.

• Overall, there are concerns regarding the punitive language of the guidance which leaves little allowance for human error and does not foster a collaborative relationship between DBHDS and community providers in order to best meet the needs of the individuals we serve.  It is also extremely discouraging to providers to have the guidance document already be in effect prior to the public comment. It is unclear how this guidance ultimately improves the quality of services being provided as it places additional administrative burdens and resulting financial costs on CSBs.

While there is a great appreciation and importance of ensuring that incidents a.) get reported and b.) get reported in a timely fashion, there are serious concerns about the ramifications being instituted by DBHDS through this proposal. 

With all of the reform that is happening in Virginia, it is concerning that DBHDS has chosen to:
1.) implement changes to a process that currently yields a 90% compliance rate
2.) shift the historical stance of DBHDS from a department that wants to support providers and assure quality through a collaborative process, to one that wants to penalize providers……because of a time-sensitive reporting process that may not even be seen by DBHDS for days.
3.) implement a process that will have an unfair impact on larger providers. They are serving more clients and have more employees, which natural increase the probability of such an incident occurring. Doesn’t seem fair.
4.) implement, yet not define when the 2 year reporting period begins and ends.  Is this at first incident? Do the time frames refresh when a license is renewed? How will this work?
5.) disregard a protocol for special circumstances that can be reviewed and considered to amend a citation (i.e., situations beyond the control of the provider).
6.) encourage providers to fear DBHDS rather than work together to improve the lives of the people we serve.
7.) not understand that this will impact the providers who are serving clients well, and understand their ethical duty to report….better late, then never.  This will not hinder the providers who are not reporting incidents at all.
8.) begin implementing this progressive citation protocol on June 15, 2020, before responding to the concerns that are presented through the Virginia Regulatory Town Hall process.

Again, it is important to ensure the reporting of incidents, and most providers are constantly working to get better.  At the end of the day we all want what is in the best interest and safety of our clients, families and employees. Let’s consider the level of care being provided before taking licenses for administrative burdens. Thanks for your consideration.

The progressive actions for citations in violation of 12VAC35-105-160D.2 or 12VAC35-45-1070.c are too punitive and do not take leave room for human error or even with possible corrective action plans in place from prior citations. The standard of no less than 4 occurrences in a two year period will be an impossible one to keep for providers and if enforced as written could have a negative effect on the provider availability for individuals with disabilities.  It is already difficulty enough to find and train staff as a provider in a field that is already struggling to pay the work force at a competitive rate without having to make no more than 4 honest errors in the course of two years without having to worry about your license being suspended.

Those of us who choose to work in this field recognize that there is something beyond ourselves that we strive to be a part of, giving back to a community we value, and putting the needs of others at the forefront of our focus. We have choices when it comes to a vocation, and when selecting one in human services, we recognize that this career is not going to get us glory, or to be rich.  It is a calling.

It is frustrating when overseers appear to be constantly looking for reasons to reprimand.  We are not perfect, but we try hard to work with people to better their lives, teach them how to manage their circumstances, value connection, and be able to look beyond themselves to see what it is that they can be a part of. 

When I look beyond myself, I recognize that I am part of a statewide system providing care to others.  I encourage my staff to work as a team to meet the needs of the individuals we serve.  I recognize that my staff are human beings and I don’t expect perfection.  I do provide guidance and feedback when needed, and there is accountability in the working relationship I have with them. What I do not do is punish or demean staff for making an error.

We operate with an adaptation of the DBT Team Agreements, and the one I point out first is the “Fallibility Agreement” which states, “We understand ahead of time that we are each fallible and make mistakes. We understand that we have probably either done whatever problematic things we’re being accused of, or some part of it, so that we can let go of assuming a defensive stance to prove our virtue or competence.” Accountability is important. It helps us to grow and better ourselves. Being demeaned and punished for mistakes does not cultivate a healthy work dynamic

With this regulation, it would appear that before too long, there will be a fair number of quality service providers who are no longer providing services to those in their community as they have lost their license to do so.  This puts a significant strain on the remaining providers to pick up additional responsibilities and provide services to even more individuals in need.  This system of care is already very heavily governed.  I don’t believe that more top-down, heavy-hitting regulations are the best solution.  

Others have commented on the lack of details explaining how this is to be executed – or the fact that is has been implemented prior to the public comment period - so I will refrain from any further discourse regarding those aspects.

The potential loss of license for late reporting of 4 incidents is a ridiculously unrealistic standard.  It disproportionately affects larger licensed programs, it incentivizes non-reporting, and could easily result in loss of community providers.  

While we appreciate the recognition that there may be unusual circumstances preventing a provider, on rare occasions, from being able to enter a report into the CHRIS system, offering only an email alternative fails to take into account the fact that a network outage may impact a provider’s ability to utilize email.  We request the establishment of a mechanism that providers may use to report an inability to access both CHRIS and email in the event of an outage.

The required timeframe to submit updates to Serious Incident Reports in CHRIS should be two business, days.  A 48-hour period does not account for the fact that many services do not operate on a seven day/week basis.  Thus, a provider may not receive an update within 48 hours.  This change would have  no negative impact on individuals receiving services and there is no gain to individuals by updating the IMU on weekends and holidays.  There is, however, a negative impact for providers, who must continue to divert funds from service delivery or other activities to pay staff members to report during the weekends and holidays.  From a more general perspective, regardless of weekends/holidays, information may not be available to providers within 48 hours and we recommend that the timeline be reconsidered.  The memo does not specify how IMU will contact providers – please share this information and ensure IMU staff are attentive to out of office messages when calling or emailing provider staff.

We appreciate efforts to standardize and publicize expectations regarding the content of CAPs and recommend revising the CAP form to promote successful fulfillment of the expectations, which benefits both the Office of Licensing and providers.  While we understand the importance of including systemic corrections, the expectations allow no latitude for the reality that some events are idiosyncratic and do not require a systemic level correction.   Please specify the timeframe allotted to Licensing Specialists to send a CAP to a provider and to review and follow up with providers after a CAP is submitted.

While we understand the need for progressive actions for repeated citations in a single area, we are highly concerned by the approach that has been implemented as it fails to use available data or to account for base rates, which vary by both size and type of provider.  The stated approach is biased against larger providers.  We highly recommend using existing CHRIS data to establish base rates for numbers of CHRS-reportable incidents by a provider’s license(s) and connecting the progressive citation to a percent of reports that are late, vs. a flat number.  A provider with late reporting for two of ten reports (20%) is quite different than a provider reporting two of fifty reports in an untimely manner (4%). 

In addition, while it is understood that multiple sites are licensed under the same type of license, this approach does not take into consideration that a provider might reasonably have sites offering the same service that fall under a different chain of command.  To conclude that if a single incident is late from each of two widely separate (either geographically or organizationally) locations there is an underlying systemic problem presumes a root cause without performing any analysis of the system or consideration of the context.   

What is the current percent of timely or untimely reporting?  What analysis has DBHDS undertaken to determine if patterns of late reports relate to specific providers or types of providers?  How was the data used to formulate an action plan?  The current approach establishes negative consequences for those who are honest in reporting/honest in late reporting and does little to monitor providers who don’t report or under report.  This elevates concerns that some providers may opt not to report at all if the report will be late.  The chances of getting “caught” doing so and the consequence are less significant than the consequences of submitting a second report a few hours late.

Please clarify and confirm that for providers with multiple licenses, the escalation of citations & consequences is by individual license, not the overarching license.  Please clarify how the two-year clock is being measured – calendar year, rolling basis, date of the provider’s license?

Referring to this as a “proposed memo” and issuance of an effective date that precedes the opening of the public comment period is highly disappointing and subverts the intent and spirit of the Town Hall process.  While we respect the importance of ensuing compliance with the terms of the DOJ Settlement agreement, we are also concerned that the manner of implementation detracts from the desired collaborative partnership with DBHDS.

Finally, we continue to have concerns regarding the economic impact of the increasing administrative burden placed on providers.  We support accountability and recognize the need to meet the terms of the DOJ Settlement agreement.  However, over the course of the past five – six years, increasing requirements on both administrative and service delivery staff have not been recognized via commensurate increases in reimbursement.  Although payment rates are not under DBHDS’s purview, from a more global perspective increased costs without increased funding result in the loss of good quality providers and services.  Staff members cannot be compensated adequately.  Funds that would be able to improve services for individuals are diverted to non-revenue generating resources, ultimately having a negative impact on individuals in need of services.  Previously issued statements that providers already have staff in place to absorb the additional duties does not accurately reflect our experience, or that of our colleagues at other agencies. 

A "guidance document" is any document developed by a state agency that provides information or guidance of a general nature to agency staff or the public to interpret or implement statutes or the agency's regulations.

Regulations have the force of law and bind regulated entities (i.e., entities that flout regulations can be punished) and the regulator (i.e., the agency/board has to follow its rules or the courts will order the agency/board to do so).

Guidance documents, on the other hand, may sometimes bind regulators but do not bind their regulated entities. Therefore, this proposed Guidance Document should not be expanding on existing regulations or creating heightened parameters or rules.

“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.,”  Guidance documents should not be used to “remind providers” of existing requirements or regulations;

“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);” The information contained in this Guidance is not as much a reminder, but a substantially impactful increase in requirements on the provider, beyond existing regulations.

“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.” Guidance document is being used as a vehicle to “inform providers” of heightened criteria for citations and sanctions?

“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.” These are compliance indicators related to the Department’s compliance with DOJ’s Settlement Agreement, not the providers’ compliance; however, DBHDS is checking off the box to show their compliance by passing the burden of implementation and the threat of sanctions to the provider.  It is of note that these are significantly impactful to the provider and do not consider the impact to the supports-delivery system:

• The draft language of this “guidance” from DBHDS is, at the least, a disheartening and tone-deaf approach by the Department that places the brunt of the burden on providers without regard to varying circumstances that may delay reporting. In addition to connectivity issues that may not fall into either the category of “CHRIS system not functioning” or “provider was unable to access the CHRIS system for reasons that were not in the provider’s control,” there are, and have been, reasonable and justified circumstances that have delayed reporting in the past and that have been recognized as such by DBHDS.  This language, however, seems to eliminate good faith circumstances by the provider or good judgment considerations by DBHDS representatives, themselves. Instead, this “guidance” seems to be providing a punitive script that providers “will be cited” – without regard to circumstances.
• In the draft language of this “guidance” from DBHDS, a situation in which a provider reports an incident at hour 25 is weighed equally (cited/sanctioned equally) with a situation in which a provider fails to report at all. If this punitive approach is meant to improve/increase provider reporting measures (or, rather, the data that DBHDS has agreed to with DOJ), it likely will have a counter-effect. It would not be surprising to see an actual decrease in initial reporting, especially in situations in which an incident may have been submitted if the provider had been able to make the determination and enter the information outside of the 24-hour deadline without threat of automatic citation.

• In the draft language of this “guidance” from DBHDS, a situation in which a provider self-indicates that they will provide an update to the initial incident report, but then fails to update until hour 49, is also weighed equally (cited/sanctioned equally) with a situation in which a provider fails to report at all. In addition to the reasons noted above, this is yet another reason why a provider is going to be less-inclined to report in the first place. Unfortunately, the majority of providers who are conscientious about reporting (and whose incident reporting makes up the 90%+ compliance of reporting) will now be less-inclined to check the box in CHRIS indicating that they have self-determined a need to provide additional information or an update, knowing that, as soon as they do, the clock starts again (and that the penalties are extremely high if anything prevents that update from occurring by hour 48).

• It is also significant to note that, while DBHDS seems to continue to expand its staff, the options and parameters for providers in regards to reporting concurrently gets more narrow, burdensome, and punitive.  Maybe the problem isn’t so much the providers but the indiscriminate layers of “solutions” that no longer seem to be vetted with stakeholders in advance to help avoid these unintended consequences. 

• Most concerning of all is that this “guidance” seems to have a one-size fits-all approach and is oblivious to the various sizes and organizational structures of provider agencies.  Not only do reporting citations result in provider sanctions (for the entirety of the provider agency) regardless of size or scope of the agency, substantial compliance, etc., it also fails to recognize that, for smaller agencies, the person(s) gathering/reviewing the information to complete the reporting may also be the person responsible for direct assurance of care and follow-up. THAT should be the emphasis, not an arbitrary reporting timeframe that is a higher standard of provider administrative availability than that of IMU staff.

The guidance memorandum issued June 3, 2020, with a stated effective date of June 15, 2020, proposes implementing progressive citation protocols by DBHDS to address repeat violations of serious incident documentation and reporting requirements. 

a.            We object that this guidance document should not be in effect as of June 15th, since the review of public comments is not yet complete. The short period between issuance and effectiveness is unreasonable and insufficient to prepare the system of providers for such a significant change.   As a large provider, we consider ourselves a partner with DBHDS yet this directive was issued unilaterally and contains punitive language, ignoring the fact that in Virginia we have a history of working as a partnership of public and private providers. 

b.            We object to the reference of a 2 year time frame to track citations since there is no definition in this document of the 2 year period, so we are unclear if it is based on a calendar, a fiscal period or based on an arbitrary date for each provider.

c.            As a large service provider with nearly 50 years of experience providing safe and quality services, we object that this guidance document has a punitive intent to add citations to providers rather than addressing the serious issue of care provision based on inadequate reimbursement and onerous reporting requirements.  We object that this memorandum is focused on effective reporting rather than improving the system of care to individuals we support.

d.            We object to the poor logic of the punitive measures which could result in provider A who is committed to risk management losing their license for a report being late by one minute while provider B shirks their responsibility fully by ignoring the need to report and hopes to avoid a citation unless discovered after the fact in an audit or quality review.  This logic does not result in an improved system of care and supports, as suggested by the Settlement Agreement.  In fact, one unfortunate result could be larger conscientious providers losing their licenses and creating a serious vacuum of care in Virginia.   

e.            We object to the requirements of 24- and 48- hour deadlines which create a significant unfunded administrative burden for large providers.  The administrative burden to collect, verify, and submit report updates is often limited by delayed access to necessary information, which is essential to produce  accurate reports based on a system of root cause analysis.

Rather than a 24 Hour Reporting requirement in CHRIS, we propose allowing 2 business days for reporting so we have adequate time to collect and analyze data in a responsible manner.

f.            We object to the 48 hour time frame to update CHRIS with medical reports or other records.  This health information comes from external sources, and we as the provider have no control over the time frames of external medical entities who are not governed by DBHDS reporting requirements.

Rather than a 48 hour follow up in CHRIS, we propose allowing an additional 2 business days for adding additional information. This is especially critical when we are awaiting medical information from external sources.  We note that, for example, waiting on results of a COVID test often takes more than 48 hours and as a provider this time frame is beyond our control.

g.            As a large provider supporting over 400 individuals, we logically experience both a higher volume of incidents and, because we support vulnerable individuals, encounter more complex incidents that require time to collect, analyze, document and report information.  As a result, we object that we, as a large provider, are more likely to reach the arbitrary threshold of four late reports because we are committed to a robust approach to risk management and quality improvement. Has the Department considered a threshold that incorporates proportionality such that the number of citations would be measured in proportion to the number of service recipients enrolled with the provider?

h.            A large provider establishing a system to ensure compliance with these requirements would need to assign a significant amount of staff resources to distinguish incidents by level, to review all reports for timeliness and completion of entry, to track that follow up is completed in a timely manner and that the agency risk and quality plan to responsively updated.  This is a significant unfunded mandate for a provider system already stretched to the limits.  There needs to be adequate accommodation within the rate setting formula to compensate providers for these administrative and managerial requirements which are beyond the DSP and first level supervision and also beyond the limited administrative overhead allowance.   It has been particularly frustrating to see additional positions added to the DBHDS budget for compliance while providers who are the providers of health and safety supports have been ignored.

It is the expectation of the providers to report incidents within 24 hours, even on weekends and holidays, when DBHDS representatives are not available.  Please revisit the language of reporting by next business day.

Please provide clarification on tracking of citations.  When does the 2 year period start? Is it for the agency as a whole or each licensed program?  Is it calendar year, fiscal year, or rolling 2 years?

As opposed to having a concrete number defining the progressive action, identifying a percentage and adjusting the time period of review would provide a more accurate reflection of trends of non-compliance.

Requiring updates to be provided in 48 hours does not allow much time for information to be gathered.  It seems that licensing specialists will be getting inundated with "updates" that only state "there is no update".  Additionally, for programs that do no provide services on weekends, there would be no staff available to provide an update to an incident that may have occurred within that 48 hour window.

The punitive nature of this guidance does not uphold a collaborative relationship between providers and DBHDS and it is difficult to see how it will actually improve the services we are providing to individuals in the community.

The requirement that all serious incidents be reported within 24 hours of the incident for providers who are offering 24 hour care is in itself unreasonable.  It would seem to be more appropriate to have a business day requirement or some other arrangement to would help providers report quickly, but in a reasonable time frame.  Be that as it may, as the only way to acceptably enter data is through the CHRIS system, the threat of a citation if outside the 24 hours window is unreasonable.   The provider's first concern should be care of the individual, not being disciplined for not reporting quickly enough.  The system is not always reliable and, even with agency systems for reporting, many providers are not IT savvy.  Often events occur when trying to report that are not within the provider's control.  If providers are held to this standard, the department should have 24/7 IT support available.

The current CHRIS system also requires that incidents that are possibly both a serious incident and a neglect/abuse be entered twice under different taps.  This is required prior to the provider having adequate time to investigate the incident.  If the provider enters it as an injury and later determines it might have been abuse, the second entry is considered a late entry.  This puts an additional burden on the provider.  This is especially true if the incident will result in a threat to the agency, which was trying to report in a timely manner, and its license.  In addition, the provider often is required by the OHR to add a neglect report, even if the provider disagrees.  This entry, under the direction of the OHR, results in a late report as well. 

The requirement to enter a follow-up within 48 hours is not reasonable.  Often doctors and hospitals do not have information to the provider in that time frame.  In addition, if an incident occurs on a weekend, 48 hours will pass with no information being made available to the provider.  The need to report at this time will result in inaccurate and incomplete information being entered.  These requirements only seem to be related to appearing to appease the DOJ, but do nothing toward providing better support and care to the individuals.  

Any threat to the license should be appealed by the provider as allowed under 37.2-415 and 37.2-418.  These will be time consuming and detract from the care of those under the provider's care.  Large providers who report regularly will be constantly fighting this issue of late reporting.  Although providers strive toward compliance, filing a report late does not indicate poor care.  

The only result of this guidance will be punishing providers who report and reducing the number of providers.  

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

I am extremely concerned about the blanket response to providers with 4 citations within a 2 year period.  The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame.  This endangers transparency for reporting.  The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.  Please consider applying the 4 repeated citations disciplinary action to "per site" instead of to large agencies as a whole.  Thank you.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

"The language within this document places additional burden upon the provider community.  This document moves into regulating through guidance.  This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame.  The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill.  If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action."

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community.  This document moves into regulating through guidance.  This language punishes providers who continue to report knowing the risk of citation outside of the 24 to 48 hour time frame.  The steps of Progressive Action for Repeat Citations does not take into account agency size including the number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill.  If the document is not pulled, it needs to be rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community.  This document moves into regulating through guidance.  The language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 time frame.  The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill.  If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

“The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.”

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

This document contains language that places an unrealistic standard on larger agencies. Larger providers who have a low percentage of late reports will still likely have more late reports than a small agency with a high percentage. If this document moves forward, it needs to be rewritten to take into account provider size in relation to progressive action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action. In the end, not renewing a license will also effect the individuals that we support, and the place they call home.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.

The language within this document places additional burden upon the provider community. This document moves into regulating through guidance. This language punishes providers who continue to report knowing the risk of citation outside of the 24 or 48 hour time frame. The steps of Progressive Action for Repeat Citations does not take into account agency size including number of locations or programs and places an unreasonable burden on larger providers that is almost impossible to fulfill. If the document is not pulled, it needs rewritten with input from stakeholders and includes language that takes into account provider size in relation to Progressive Action.