Virginia Regulatory Town Hall
Agency
Department of Behavioral Health and Developmental Services
 
Board
State Board of Behavioral Health and Developmental Services
 
Guidance Document Change: The purpose of this memorandum is to remind DBHDS licensed providers of the requirements and expectations for reporting serious incidents to the DBHDS Office of Licensing, pursuant to 12VAC35-46-1070.C. and 12VAC35-105-160.D.2., including the timeframe for reporting incidents; the process for reporting incidents; the allowable timeframe for adding to, amending, or correcting information reported to the Office of Licensing through the Computerized Human Rights Information System (CHRIS); and to inform providers of the processes that the Office of Licensing will follow for issuing citations, repeat citations and sanctions for violations of serious incident reporting requirements. In addition to ensuring all providers understand the regulatory requirements associated with reporting incidents, the processes outlined in this memo are central to the department’s efforts to address compliance indicators related to serious incident reporting as mandated by the US Department of Justice’s (DOJ) Settlement Agreement with Virginia.
Previous Comment     Next Comment     Back to List of Comments
7/22/20  4:57 pm
Commenter: Stephanie Terrell - Rappahannock Area Community Services Board

Incident Reporting Requirements
 

Comment: The short period between the, June 4, 2020, publication of the guidance document and the effective date, of June 15, 2020, does not grant the system of providers to prepare for such significant changes.  In addition, the effective date precedes the public comment period. 

 

Comment:  In the draft language of the “guidance “ from DBHDS states the only valid reasons a for not reporting a serious incident into CHRIs includes: “1) The CHRIS system was not functioning at the time the incident was discovered; or 2) The provider was unable to access the CHRIS system for reasons that were not in the provider’s control. If a provider is unable to report a serious incident through the CHRIS system for one of these valid reasons, then the provider must notify the Office of Licensing’s Incident Management Unit (IMU) via e-mail (incident_management@dbhds.virginia.gov) of the provider’s inability to report the incident through the CHRIS system within 24 hours of the discovery of the incident.”   Offering only an email alternative fails to take into account that the network outage may impact the providers ability to utilize email.  In addition there may be reasonable and justifiable circumstances that delay reporting; however the language in the “guidance document: seems to eliminate good faith circumstances by the provider.

 

Comment: Establishing a system to ensure compliance with the requirements would require a significant amount of staff resources.  The 24 (initial report) and 48 hour (follow-up) reporting requirements create significant administrative burden for large provider.  The administrative burden to collect, verify, and submit a CHRIS report is often limited by delay of access to necessary information, which is essential to produce accurate reports.

 

Comment: In the draft language of the “guidance“  from DBHD, providers who self-reports that an update to the CHRIS report will be provided are required to do so within 48 hours from the initial submission.  Failure to update the CHRIS report within 48 hours from the initial submission will result in a citation.  It should be noted that there are instances in which updates may not be possible in the required time requirement as the provider may be waiting on medical reports or other reports related to an emergency room visit.  Limiting the required timeframe to 48 hours limits the ability to provide detailed information. 

 

Comment: In the draft language of the “guidance“ from DBHD the 2 year time frame to track citations is not defined.  It is unclear if it is based on calendar, fiscal period, or based on an arbitrary date for each provider. 

 

 Comment:  In the draft language of the “guidance“ from DBHD all providers are weighed equally in situation regarding incident reported beyond the 24 or 48 hour requirement regardless of the lateness, or the size or scope of the agency.   This approach establishes negative consequences for those who are conscientious and honest in reporting and has minimal or no impact on monitoring providers who do not report or under report.  

 

 

CommentID: 84151