Settlement Agreement Provision
The Commonwealth shall have and implement a process to investigate reports of suspected or alleged abuse, neglect, critical incidents, or deaths and identify remediation steps taken. The Commonwealth shall be required to implement the process for investigation and remediation detailed in the Virginia DBHDS Licensing Regulations (12 VAC 35-105-160 and 12 VAC 35-105-170 in effect on the effective date of this Agreement) and the Virginia Rules and Regulations to Assure the Rights of Individuals Receiving Services from Providers Licensed, Funded or Operated by the Department of Mental Health, Mental Retardation and Substance Abuse Services (“DBHDS Human Rights Regulations” (12 VAC 35-115-50(D)(3)) in effect on the effective date of this Agreement, and shall verify the implementation of corrective action plans required under these Rules and Regulations.
About Investigations and Corrective Actions
DBHDS has established protocols for investigating reports of serious incidents or deaths as well as monitoring providers’ investigations of abuse and neglect allegations as required in regulation. Corrective action or remediation is included in regulatory requirements and monitoring the implementation of those actions is conducted per the DBHDS Offices of Licensing and Human Rights protocols.
DBHDS monitors compliance with the serious incident reporting requirements of the Licensing Regulations as specified by DBHDS policies during all investigations of serious injuries and deaths and during annual inspections. DBHDS implements an incident management process that is responsible for review and follow-up of all reported serious incidents, as defined in the Licensing Regulations. DBHDS reviews and approves corrective action plans that are in response to serious incidents, abuse, neglect, or death in accordance with the Licensing and Human Rights Regulations.
Authorizing Authority
Processes, Protocols and Standards
- Imminent Danger Memo-Final-10.7.19-Revision April 2024
- Human Rights Protocols:
- Connect Health and Safety CAP Process (April 2023)
Instruments and Tools
- Investigation Training Manual
- Investigating Abuse & Neglect: An Overview for Community Providers
- Licensed Provider Coaching Seminar II (July 2023)
- Optional Investigation Form
- Investigation Review Sheet
- Investigation Protocol Chapter-Revised for Connect Nov 2022
- Mortality Review Document Submission Process (January 2023)
- Mortality Review Committee Submission Checklist (July 2022)
- Mortality Review Committee Document Submission Memorandum (July 2019)
- Contacting 911 Emergency Services (December 2019)
Guidelines, Charters, Plans, Other
- LIC17 Guidance for Serious Incident Reporting
- LIC20 Guidance on Incident Reporting Requirements
- LIC19 Guidance on Corrective Action Plans
For more information about Investigations and Corrective Actions:
http://dbhds.virginia.gov/quality-management/Office-of-Licensing
https://dbhds.virginia.gov/quality-management/human-rights/training-resources-for-providers/