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12VAC35-105-160 - Reviews by the department; requests for information; required reporting (Serious Incident Reporting)

VirginiaregulationVirginia Department of Behavioral Health and Developmental Services (DBHDS), Office of Licensing· effective 2020-08-01

What this rule requires your agency to do

  • 1The provider must report Level II and Level III serious incidents using the department's (DBHDS) web-based reporting application and by telephone or email within 24 hours of discovery. (12VAC35-105-160 D)(12VAC35-105-160 - Reviews by the department; requests for information; required reporting (Serious Incident Reporting))
  • 2The provider must notify anyone designated by the individual to receive such notice and the individual's authorized representative of the serious incident within 24 hours of discovery. (12VAC35-105-160 D)(12VAC35-105-160 - Reviews by the department; requests for information; required reporting (Serious Incident Reporting))
  • 3The root cause analysis must include a detailed description of the incident, an analysis of underlying causes within the provider's control, and identified solutions to prevent recurrence. (12VAC35-105-160 E)(12VAC35-105-160 - Reviews by the department; requests for information; required reporting (Serious Incident Reporting))
  • 4The provider must conduct a root cause analysis within 30 days of discovery of a Level II serious incident and of any Level III serious incident that occurs during service provision or on the provider's premises. (12VAC35-105-160 E)(12VAC35-105-160 - Reviews by the department; requests for information; required reporting (Serious Incident Reporting))
  • 5The provider must collect, maintain, and review at least quarterly all serious incidents, including Level I serious incidents, as part of its quality improvement program, analyzing trends and implementing remediation. (12VAC35-105-160 C)(12VAC35-105-160 - Reviews by the department; requests for information; required reporting (Serious Incident Reporting))
  • 6The provider must include in the serious incident report the date, place, and circumstances of the incident, and for incidents involving injury or death, the nature of the harm or condition. (12VAC35-105-160 D)(12VAC35-105-160 - Reviews by the department; requests for information; required reporting (Serious Incident Reporting))

Applies to: home and community-based services (DD waiver / community-based behavioral health providers licensed by DBHDS)

Virginia's DBHDS licensing regulation for community (home and community-based) services requires providers to report serious incidents. Level II and Level III serious incidents must be reported via the department's web-based reporting application and by phone or email within 24 hours of discovery; a root cause analysis must be conducted within 30 days; and all serious incidents (including Level I) must be reviewed at least quarterly through the provider's quality improvement program.

Regulatory information, not legal advice — always confirm against the cited official source. Verification reduces error; it does not certify compliance.