Settlement Agreement Provision
The Commonwealth shall require all providers (including Training Centers, CSBs, and other community providers) to develop and implement a quality improvement (“QI”) program, including root cause analyses, that is sufficient to identify and address significant service issues and is consistent with the requirements of the DBHDS Licensing Regulations at 12 VAC 35-105-620 in effect on the effective date of this Agreement and the provisions of this Agreement
The Commonwealth shall use Quality Service Reviews and other mechanisms to assess the adequacy of providers’ quality improvement strategies and shall provide technical assistance and other oversight to providers whose quality improvement strategies the Commonwealth determines to be inadequate.
About Provider Quality Improvement
DBHDS, through its regulations, requires DBHDS-licensed providers, including CSBs, to have a quality improvement (QI) program that: a. is sufficient to identify, monitor, and evaluate clinical and service quality and effectiveness on a systematic and ongoing basis; and, b. uses standard quality improvement tools, including root cause analysis. DBHDS has published written guidance for providers on developing and implementing the requirements of these regulations (12 VAC 35-105-620) including reviewing serious incidents as part of the quality improvement program. Guidance is updated and revised as necessary as determined by DBHDS.
In addition to monitoring provider compliance with the DBHDS Licensing Regulations governing quality improvement programs, the Commonwealth assesses and makes a determination of the adequacy of providers’ quality improvement programs through the findings from Quality Service Reviews, which assess the adequacy of providers’ quality improvement programs. Using information collected from licensing reviews and Quality Service Reviews, the Commonwealth identifies providers that have been unable to demonstrate adequate quality improvement programs and offers technical assistance as necessary.
Authorizing Authority
Processes, Protocols and Standards
Instruments and Tools
- 2023 Annual Inspections for Providers of Developmental Services Revised 1.17.23
- Risk-Triggers-and-Thresholds-Handout-1.1.23
- IMU_Care Concern Training_Effective 1.1.2023_Final
- 2023 Care Concern Thresholds Criteria_OL MEMO_Final
- Care_Concern_Protocol_IMU_rev 1.1.2023_indic 29.31_29.32
- Tracking of Level I Serious Incidents vs. Baseline Behaviors Memo
- Tools for Developing a Quality Improvement Program 02.2022
- Sample Provider Quality Improvement Plan
Training Materials
- Licensed Provider Coaching Seminar III (July 2023)
- Quality Improvement Training November 2022
- Regulatory Compliance with Quality Improvement Regulations 12-21
- Quality Improvement Tips and Tools 6-2021
- QI-RM-RCA Webinar Recording December 2021 (February 2022)
- Quality Improvement Strategies Training by the Center for Developmental Disabilities Evaluation & Research – Recorded Webinar (December 2020)
- Frequently Asked Questions 12VAC35-105-620
For more information about Provider Quality Improvement:
dbhds.virginia.gov/developmental-services/provider-development