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.