12VAC35-105-170. Corrective action plan.

H. The provider shall monitor implementation and effectiveness of approved corrective actions as part of its quality improvement program required by 12VAC35-105-620. If the provider determines that an approved corrective action was fully implemented, but did not prevent the recurrence of a regulatory violation or correct any systemic deficiencies, the provider shall:

1. Continue implementing the corrective action plan and put into place additional measures to prevent the recurrence of the cited violation and address identified systemic deficiencies; 

2VAC35-105-620. Monitoring and evaluating service quality.

3. Submit revised corrective action plans to the department for approval or continue implementing the corrective action plan and put into place additional measures to prevent the recurrence of the cited violation and address identified systemic deficiencies when reviews determine that a corrective action was fully implemented but did not prevent the recurrence of the cited regulatory violation or correct a systemic deficiency pursuant to 12VAC35-105-170.

While there are continuous efforts to mitigate risk of regulatory violations, we do not always have the ability to eliminate that risk. Therefore, requiring a corrective action plan to prevent recurrence of any regulatory violations is impossible, especially when that violation is a delayed report. Asking providers to completely prevent future incidents remains an unattainable goal and positions providers to fail despite the best of efforts or intentions. We are unable to guarantee future access to all necessary parties or ensure the speed of test results, which are essential to meet this requirement.

Instead of “prevention,” maintaining the use of the language in 170 C.1, to “minimize the possibility that the violation will occur again,” throughout the licensing regulation document provides the consistent intent of systemic improvements within a reality-based framework.