Updates to Serious Incident Reports
We recommend allowing a longer period of time to update CHRIS after the initial incident report, for example up to 3 business days. The 48 hour requirement is not adequate for programs to obtain appropriate followup information (e.g., lab tests, schedule medical appointments, interviews with staff, etc.), particularly if the incident occurred on a weekend or holiday.

Corrective Action Plans (CAPs) – Minimum Requirements
We are concerned about the requirement for CAPs to include “systemic actions to ensure future compliance with the regulation.”  Sometimes, after a review of an incident, we find there is not a systemic issue. An incident could be due to a staff member oversight / mistake; this should be addressed with the staff member. Allocating time and resources towards systemic solution when there is not a systemic issue creates unnecessary, additional work.

Progressive Actions for Repeat Citations
1) DBHDS should clarify when the two year period begins that lead to progressive citations (e.g., is it by fiscal year, calendar year, etc.)

2) We are very concerned with how this progressive action will impact larger providers. We believe the size of the agency/program should be considered. A large program with multiple locations and many more staff may experience a couple of staff specific situations who fail to follow guidelines which may not be indicative of a systemic issue. Whereas a smaller program with the same number of occurrences may indicate systemic issues.
This may lead to providers under-reporting incidents because of the punitive nature of this progressive action and the impact it has on their license.