Comment in response to Guidance Document on Incident Reporting Requirements;

The purpose of this guidance appears to continue to point to the area of citations and the movement of increased issuance of additional citations and progressive actions for repeat citations.

Information outlined within this guidance document sets a requirement for updates to serious incidents taking place within 48 hours from the initial submission. This does not allow appropriate time to have necessary information to report an update for many situations. For incidents that may require the need for additional follow up information this is often due to lab results, testing, etc. in which Providers may not have the updated information at that time as this information is often requested from outside entities. This requirement needs to be extended to account for the realistic time outline that Providers are dealing with.

In the use of a software platform as a departmental reporting system, it appears necessary to have potential flexibilities that may arise from situations that may surface due to technological associated glitches or failures; however there appears to not be any flexibilities for Providers in reporting. Essentially the need for reporting is to ensure proper reporting standards are met and not necessarily a time stamp data collection task. Although it is understandable to have providers adhere to submitting reporting in a timely manner, the strict focus on 24 hours at times is not realistic, therefore there does need to allow for some flexibilities that may surface.

Within the progressive actions for repeat citations; Although this guidance document is in a comment period there is reference to the noted progressive actions beginning “June 15, 2020”; this does not allow for proper preparation, notification, etc. across the system in outlining a date that begins prior to a final document being approved and released. This date needs to be removed.

The outline of progressive action steps in relation to the implementation of a specific number of citations that do not account for the size, location, service settings, etc. appears to be an error. Having one service setting have a total of four CAPs occur is concerning and agreed as an area of attention and focus; however having a total of four CAPs occur within two years for an agency that has close to 400 service locations could be viewed very differently. The larger the agency the more likely that investigations, incidents, etc. may occur. Additionally, the section code reference can quickly add up to being considered as part of the progressive action in that it references section code 160 and 1070 both of which could encompass an array of various regulation violations.

It is recommended that progressive action be eliminated from language that is contained within a reference document.

Thank you for your time and consideration.