VNPP Responds to Issues Raised in OIG Report

January 22, 2018

It is inevitable that a report such as that released by the OIG, coupled with the announcement this weekend that a Virginia provider’s staff was arrested for causing the injuries sustained by an individual who was restrained,  will raise concerns about the quality of the services provided in Virginia; VNPP supports transparency in both how injuries, deaths and other serious incidents are investigated and reported and in helping all of our members develop internal Quality  Management protocols that are of the highest standard.

We recognize that our membership is diverse in experience, size and capacity for meeting the expectations for quality management; some are CARF accredited, some have substantial quality management capacity, and some are smaller with limited management staff.

Here are three Steps which may be helpful:

Step 1 – required by the regulations which govern our services, is to report any allegation of abuse, neglect or exploitation or any serious injury or death.

  • DBHDS has focused on timely reporting; but VNPP would encourage that each provider develop an internal quality measure which allows the Executive Management to assess the timeliness of the reporting of all incidents.


Step 2 – based on the past practice of incident investigation, many providers have structured their practice to complete a review of staff behavior either which may have caused the incident/injury or when the incident/injury was discovered; corrective action is based on these findings.

  • Some providers do not have robust quality management procedures for either completing a root cause analysis or for analyzing patterns in reported incidents which might suggest systemic issues.


Step 3 – using summary data available in the CHRIS system, compared to data assembled internally to ensure accuracy, each provider should be prepared to answer the following questions:

  • Compared to daily documentation were all serious injuries, serious medication errors (requiring medical attention), allegations of abuse, neglect or exploitation reported within 24 hours; were all investigations completed within specified timeframes?  If not, why not? What can be done to prevent future errors?

  • Using an adequate sample of each type of incident, what was the root (not immediate) cause?  What trend data can be developed from your findings? What corrective action would be minimize the risk of incidents recurring?


This broad outline should offer a framework for examining policies,  procedures and practices.  Those with more robust Quality Management programs are already using these and other benchmarks.