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 Ends 7/22/2020
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7/13/20  4:09 pm
Commenter: Nancy Hopkins-Garriss, Pleasant View, Inc.

Comment on Regulatory Action--CAP

Under 12 VAC35-105-170 C, providers are required to submit a corrective action plan (CAP) outlining actions to be taken to minimize the possibility that the violation will occur again.  This requires correcting any systemic issues which might lead to the issue in another location operated by the provider.  Minimizing the possibility of violation is a reasonable goal.  Providers desire to provide the best supports possible to our individuals.

Under 12 VAC35-105-170 H, the provider is held to a standard that is unachievable by stating the corrective action plan would prevent recurrence.  The provider is expected to include the expectation to prevent recurrence as part of the Quality Improvement plan.  

The standard of preventing recurrence is an impossible standard to meet.  This is particularly difficult for providers with multiple locations.  During a review at one site, an issue such as a small maintenance need could be cited and then later a non-related issue that falls under the regulation at another location is cited.  If these are cited on different CAPs under the same regulation, multiple citations would be considered a "systemic" issue.  To have a CAP that can cover all contingencies and ensure no more violations is impossible and will lead to additional citations.  The purpose of a CAP should to to improve services and ensure that supports are best practice.   To expect perfection across numerous programs and situations when working with human beings is not realistic.  

12VAC35-105-170-H and 12VAC34-105-D-3 should be removed from the Final regulations.  

CommentID: 83888