I agree with many of the comments that have already been submitted as there are several issues of concern with the memo as it is currently written.  In addition, I hope you will consider the following:  

Purpose: 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......

 Comment:  I doubt there is a single provider who needs to be reminded of the requirements and expectations for reporting serious incidents.  It is constantly on the mind of everyone who has been tasked with that responsibility in their agency.  It is now a major part of their jobs because they have to train staff, send reminders, provide supervision, answer the phone on weekends and at all hours of the night, receive reports, enter the incidents into CHRIS, gather additional data to update the reports, discuss incidents with DBHDS staff, review incidents during annual inspections, and on and on and on.  After reading the memo, it didn’t seem like it was written to remind providers, but to increase the requirements and expectations for the sake of the DOJ Settlement Agreement.  

Attachment 1 of the DOJ Settlement Agreement, Provision V.C.6, number 4 states:

At least 86% of reportable serious incidents are reported within the timelines set out by DBHDS policy.

 Comment:  According to a Risk Management Review Committee (RMRC) SFY 2020 handout dated June 2020, providers met this requirement in FY19 with 93% compliance and the first three quarters of FY20 have been 93%, 89% and 93%.  If providers are currently surpassing the requirement, what prompted DBHDS to issue a 6 page memo outlining new processes for issuing citations, repeat citations and sanctions for violations of serious incident reporting requirements?  Why is this needed for an indicator we are already meeting?  Wouldn’t it be more prudent to focus on indicators that we have not yet met? 

Office of Licensing Compliance Monitoring Activities

The Office of Licensing conducts ongoing daily monitoring of provider compliance with serious incident reporting requirements. The IMU within the Office of Licensing reviews serious incident reports daily for timeliness and compliance with all other regulatory requirements.

 Comment:  The memo states that the Office of Licensing conducts ongoing daily monitoring of provider compliance and reviews serious incident reports daily. We have been told that the Office of Licensing staff do not work on the weekends.  If that is true, these statements should be removed.  That being said, it is interesting that DBHDS is holding providers to a higher standard by requiring them to report incidents on weekends, when their own staff are not required to work.  If an incident reported Friday night is not viewed by Office of Licensing staff until Monday morning, then the provider shouldn’t have to report it until Monday morning.   

Final Comment:  If this “guidance” remains in effect, is DBHDS ready to deal with the consequences of these stringent requirements?  When providers reach the 4 citation limit (and it will likely happen, especially at larger agencies), licenses will be suspended or revoked.  Staff will lose their jobs.  Clients will lose their services.  Who will pick up the slack?  What will happen then?