Settlement Agreement Provision
The Commonwealth shall have and implement a real time, web-based incident reporting system and reporting protocol. The protocol shall require that any staff of a Training Center, CSB, or community provider aware of any suspected or alleged incident of abuse or neglect as defined by Virginia Code § 37.2-100 in effect on the effective date of this Agreement, serious injury as defined by 12 VAC 35-115-30 in effect on the effective date of this Agreement, or deaths directly report such information to the DBHDS Assistant Commissioner for Quality Improvement or his or her designee.
If the Training Center, CSBs, or other community provider fails to report harms and implement corrective actions, the Commonwealth shall take appropriate action with the provider pursuant to the DBHDS Human Rights Regulations (12 VAC 35-115- 240), the DBHDS Licensing Regulations (12 VAC 35-105-170), Virginia Code § 37.2-419 in effect on the effective date of this Agreement, and other requirements in this Agreement.
About Incident Reporting System
The Computerized Human Rights Information System (CHRIS) is the DBHDS web-based real time incident reporting system. DBHDS licensed providers are required to report serious incidents as well as allegations of abuse, neglect and exploitation to the Department using this web-based application. Provider reporting requirements are prescribed in the DBHDS Licensing Regulations and its Human Rights Regulations. The Department provides guidance and training on the use of this system. CHRIS reports are produced and monitored for regulatory compliance and quality improvement purposes.
Authorizing Authority
- § 37.2 – 41 1 Code of Virginia
- 12 VAC35 35 -105. 160 and 170
- DI 401 regarding TC reporting of incidents
Processes, Protocols and Standards
- Rules and Regulations for Licensed Providers
- LIC 20: Guidance on Incident Reporting Requirements (August 2020)
- LIC 17: Guidance for Serious Incident Reporting (November 2020)
- Level 1 Serious Incidents v. Baseline Behaviors Memo
- CHRIS Changes – Abuse and Neglect Reporting (July 2023)
- 2023 Care Concern Threshold Criteria Memo
- Incident Management Unit Look Behind Process and Provider Responsibilities
Instruments and Tools
- DBHDS Computerized Human Rights Information System (“CHRIS”) (DBHDS web-based incident reporting system) (Abuse allegation template)
- Death/Serious Injury Report Template
- Sample Root Cause Analysis Policy (February 2022)
- Flow-Chart Incident Reviews (April 2023)
- Risk Triggers and Threshold Handout (February 2023)
- Serious Incident Review and Root Cause Analysis Template (April 2023)
- Individual Risk Tracking Tool (April 2023)
- Monthly Risk Tracking Tool (April 2023)
Training Materials
- Serious Incident Reporting-Covid-19 (December 2022)
- Individual and Systematic Risk – How to Report and Respond to Incidents (April 2022)
- Memo – Revoking A User Access (February 2020)
- CHRIS System Training (May 2021)
- Creating A New Serious Incident Case (August 2019)
- Creating A New Death Case (August 2019)
- Updating A Serious Incident (August 2019)
- Updating A Death Record (August 2019)
- DELTA Overview
- DBHDS Office of Licensing Training specific to: Serious Incident Reporting CHRIS training
- Reporting in CHRIS: Abuse, Neglect, Exploitation and Human Rights Complaints (January 2022)
- Licensed Provider Coaching Seminar II (July 2023)
- Day 2: Minimizing Risk Session 2 PowerPoint (April 2023)
- Instructional Video: Minimizing Risk Day 2
- IMU Care Concern PowerPoint (February 2023)
- Instructional Video: Risk Tracking Tool (April 2023)
For more information about Incident Reporting System: