Home » Incident Reporting System » Reporting

Incident Reporting System

Reporting

Settlement Agreement Provision

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.

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.

Reports

Compliance Indicators

Compliance Indicators V.C.6

  1. DBHDS identifies providers, including CSBs, that have failed to report serious incidents, deaths, or allegations of abuse or neglect as required by the Licensing Regulations. Identification occurs through:
    1. Licensing inspections and investigations;
    2. DBHDS receipt of information from external agencies, such as the protection and advocacy agency, or other agencies such as the Department of Health or local adult protective services agencies;
    3. Any other information that DBHDS may receive from individuals, other providers, family members, or others;
    4. Reports of deaths from the Virginia Department of Health as described in Indicator 7.c of V.C.5.
  2. To validate that medical-related incidents are reported as required, at least annually, the Commonwealth conducts a review of Medicaid claims data and how it correlates to serious incidents reported to DBHDS. This review will be done of individuals enrolled in the DD waivers who receive one of the following waiver services: group home residential, sponsored residential, and supported living. Data related to Medicaid claims screened includes services associated with reporting requirements for:  i. emergency room visits; and ii. hospitalizations.
  3. One quarter of data related to Medicaid claims is reviewed per calendar year for each of the following DD waivers under the direction of DBHDS:
    1. Building Independence
    2. Family and Individual Supports
  4. At least 86% of reportable serious incidents are reported within the timelines set out by DBHDS policy.
  5. Providers, including CSBs, that fail to report serious incidents, deaths, or allegations of abuse or neglect as required by the Licensing Regulations receive citations and are required to develop and implement DBHDS-approved corrective action plans. 
  6. 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.  DBHDS follows-up on approved corrective action plans to ensure that they have been implemented and are achieving their intended outcomes as follows:
    1. For serious injuries and deaths that result from substantiated abuse, neglect, or health and safety violations, the Office of Licensing verifies that corrective action plans have been implemented within 45 days of their start date.
    2. In cases of substantiated abuse or neglect that do not involve serious injury or death, the Office of Human Rights verifies that corrective action plans have been implemented within 90 days of their start date.
    3. On an annual basis, at least 86% of corrective action plans related to substantiated abuse or neglect, serious incidents, or deaths are fully implemented as specified in this indicator or, if not implemented as specified, DBHDS takes appropriate action as determined by the Commissioner in accordance with the Licensing Regulations.
  7. Providers, including CSBs, that have recurring deficiencies in the timely implementation of DBHDS-approved corrective action plans related to the reporting of serious incidents, deaths, or allegations of abuse or neglect will be subject to further action as appropriate under the Licensing Regulations and approved by the DBHDS Commissioner.
  8. DBHDS has Policies or Departmental Instructions that specify requirements for Training Centers to report serious incidents, including, deaths, or allegations of abuse or neglect and to implement and monitor corrective actions.
    1. DBHDS has a process to monitor the implementation of corrective actions.
    2. When DBHDS identifies that harms have not been reported in accordance with policies or Departmental Instructions, an analysis is conducted to identify root causes; DBHDS implements corrective action as necessary to address identified causes.

    |