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.