Risk Management

Permanent Injunction

42. To ensure that the risk management programs of DBHDS licensed providers of DD services identify the incidence of common risks and conditions faced by people with DD that contribute to avoidable deaths and take prompt action when such events occur or the risk is otherwise identified, the Commonwealth will take the following actions:
1. Within 24 months of the date of this Order, the Commonwealth shall establish inter-rater reliability among the Commonwealth’s licensing specialists regarding provider compliance with the quality assurance trending requirements.
2. Within 12 months of the date of this Order, the Commonwealth shall offer technical assistance in accordance with DBHDS’s Consultation and Technical Assistance Standard Operating Procedure to each provider that does not identify the incidence of common risks and conditions faced by people with DD that contribute to avoidable deaths.
3. Within one month of the date of this Order, when providers do not take prompt action when such events occur, or where the risk is otherwise identified despite lack of prompt action by providers, DBHDS will ensure that corrective action plans are written, implemented, and tracked, and take further actions as warranted.

55. The Commonwealth will work to achieve a goal that at least 86% of DBHDS-licensed providers of DD services have been assessed for their compliance with risk management requirements in the Licensing Regulations during their annual inspections. DBHDS will continue to conduct annual licensing inspections in accordance with Virginia Code § 37.2-411 in effect on the date of this Order or as may be amended and assess provider compliance with risk management requirements in the Licensing Regulations utilizing the Office of Licensing Annual Compliance Determination Chart.

Settlement Agreement

The Commonwealth shall require that all Training Centers, CSBs, and other community providers of residential and day services implement risk management processes, including establishment of uniform risk triggers and thresholds, that enable them to adequately address harms and risks of harm. Harm includes any physical injury, whether caused by abuse, neglect, or accidental causes

About Risk Management

The DBHDS Risk Management Review Committee (RMRC) has created an overall risk management process for DBHDS that enables DBHDS to identify, prevent or substantially mitigate, risks of harm for recipients of DD services. The Licensing Regulations require all licensed providers, including CSBs, to implement risk management processes. DBHDS publishes guidance and recommendations for providers on risk management requirements, along with recommendations for monitoring, reducing, and minimizing risks associated with chronic diseases, identification of emergent conditions and significant changes in conditions, or behavior presenting a risk to self or others. DBHDS monitors to ensure providers appropriately respond to and address risk triggers and thresholds using Quality Service Reviews, or other methodology. The RMRC produces reports on DBHDS risk management activities and presents recommendations to the DBHDS Quality Improvement Committee as appropriate.