Response to Guidance Document re: 12VAC35-105-520

A. Regarding the statement “A person responsible for risk management function who has completed department approved training”: 

1. Is the intention that there is an individual who is directly responsible for completing each of the items listed in A or is it also appropriate that there be a risk manager who oversees a group of people who are completing those activities?  For larger organizations this would be the only way possible to manage the risk management activities required. 

   1. Wording suggestion “… designate a person responsible for the risk management activities of the organization.  The risk manager shall have completed department approved training which includes….  The risk manager shall ensure that all individuals supporting organizational risk management activities have completed risk management training relevant to their specific risk management job responsibilities. “
2. It is unclear whether the expectation is that the person delegated to be the Risk Manager shall have completed the required training listed as part of their oversight duties or is the expectation that all people involved in any risk management function be trained in all the areas.  If it is the second, this is problematic for larger entities where many of the specific risk management activities are delegated to separate individuals who specialize in certain functions.

B. No comment

C (1)  It is recommended that the guidance document should include the same language as the code which states that an assessment of environment of care means “a safety inspection has been performed at least annually of each service location owned, rented, or leased by the provider”.  Clarification should be made in the guidance document that organizations, even County run CSBs, are unable to do safety inspections at every location where service is provided as they can include jails, schools, the community and or private homes.

C (2) Regarding the clinical assessment or reassessment --  the review of an individual’s health risk should be conducted by the case manager/treatment team as part of the treatment provided by the organization and not a specific risk manager who most likely has nothing to do with the direct provision of clinical services.  While the organization should look to see if assessments are completed and plans changed as appropriate through either risk management activities and/or quality improvement activities, neither department would be expected to directly review individual health risks.  Please clarify the responsibilities of the risk manager when it comes to the review of the individual’s health risks.

C (3) No comment                           

C (4) Overall no concern regarding the expectation but it would be helpful to have examples of what is considered a high-risk procedure. 

C (5) No comment

D.  We are unable to comment on something that is yet undefined.  Please clarify what is meant by thresholds and triggers.

E. This seems to be a duplication of C1.  Please clarify what the difference is between a safety inspection and a risk assessment of the environment of care.  As we stated in our comments for C1 the department should be specific that are unable to do safety inspections at every location where service is provided as they can include jails, schools, the community and or private homes.

F. The department has been clear about what constitutes a serious injury to persons served.  It is suggested that the department be equally clear about what defines a serious injury to a staff member/visitor.