C.3 refers to “statewide performance measures" – can clarification be provided on what these measures are and where they are located

D.3. -this appears to operate on the assumption that all CAPs and violations are a result of systemic deficiencies and does not include other situations that may not reflect a systemic issue

- “prevention of recurrence” sounds like a good goal, but an unrealistic expectation to have of all providers – changing the language to better capture CAPS as mitigating and minimizing the likelihood of recurrence may be more accurate