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  4:57 pm
Commenter: R. Cote

Corrective Action Plans

Example for Creating a CAP – After an unannounced inspection, Provider A receives a licensing report on August 1st that includes the second citation for late reporting within a one-year period.

    1. Isn’t this supposed to be a 2 year period? Or is 1 year just as an example?

#1 conduct a RCA in accordance with the written quality improvement program, to determine the root cause of these systemic violations.

    1. Is this a required part of all quality improvement programs?

#2c – (also reviewed in b.) if there are policy/procedure/form changes that are required to be submitted as a part of the CAP BY THE DUE DATE, this may be impossible to meet due to the need for the Board to approve policy changes or the time it may take for forms to be updated especially as the due date is only 15 business days.

CommentID: 84152