Virginia Regulatory Town Hall
Department of Behavioral Health and Developmental Services
State Board of Behavioral Health and Developmental Services
Rules and Regulations For Licensing Providers by the Department of Behavioral Health and Developmental Services [12 VAC 35 ‑ 105]
Action Compliance with Virginia’s Settlement Agreement with US DOJ
Stage Final
Comment Period Ended on 7/22/2020
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7/22/20  5:00 pm
Commenter: R. Cote

Corrective Action Plans

Implement CAP by the date of completion indicated in the plan; Guidance – For serious injuries and deaths resulting from substantiated abuse/neglect/health & safety violations, OL verifies corrective action plans have been implemented within 45 days of their start date

    1. Is it the responsibility of the agency or the specialist to ensure that the specialist has verified the CAP has been implemented?

H. Provider shall monitor implementation and effectiveness of CAP … If provider determines that an approved CAP was fully implemented but did not prevent the recurrence of a regulatory violation or correct any systemic deficiencies, the provider shall: continue plan and put into place additional measures to prevent the recurrence of cited violation and address identified systemic deficiencies; or submit a revised corrective action plan to the department for approval

    1. Wouldn’t a recurrence of a cited violation result in a new citation that is now deemed “systemic” if it is the 2nd time in less than 2 years?
    2. If the CAP did not prevent a recurrence of the regulatory violation, would submission of a revised CAP prior to a new citation being written prevent an additional citation?
CommentID: 84154