12VAC35-105-170: 

Include the specific time frame the DBHDS staff person issuing the CAP has to respond to the provider when they submit their corrective action plan AND/OR any questions they have about it.  DBHDS seemingly has no accountability for timely response to CAPs or questions despite the numerous deadlines imposed on providers.  

12VAC35-105-170 C:  “If a CAP is returned to the provider a second time for failure to meet all requirements within 12VAC35-105-170.C., the licensing specialist will offer to have a phone call with the provider to provide technical assistance related to the criteria needed to create an acceptable CAP.”

Will the department provide transcripts of these phone calls or will it be the responsibility of the provider to record the conversation to ensure continuity between licensing specialists? 

12VAC35-105-170 C:  “If a CAP is returned to the provider a third time for failure to meet all requirements within 12VAC35-105-170, the CAP will be returned with an additional citation for violating regulation 12VAC35-105-170.C.  and the CAP dispute process will be initiated automatically as outlined in 12VAC35-105-170.F”

By issuing an additional citation to a provider for essentially not agreeing with or not fully understanding a licensing specialist, DBHDS is unnecessarily intimidating providers into making greater systemic changes than  necessary simply to avoid having their CAP rejected enough times to cause yet another citation.  

If after the one phone call the licensing specialist is required to offer, the provider and licensing specialist still aren’t able to resolve the CAP issue then the dispute process should be automatically initiated.  The additional citation serves no other purpose than to be adversarial.

The dispute process is often one of the few ways a provider supporting multiple regions of Virginia can receive consistent guidance between multiple licensing specialists.  And now with the addition of the incident management unit, investigators, etc., there will be even greater discrepancy between DBHDS staff. 

However, now that DBHDS has so many new staff in place, they can afford the extra time to complete the dispute process as opposed to discouraging it with threat of citation.

It is also noted that the guidance document does not indicate whether the additional citation will be removed should the dispute process end in favor of the provider.  This is another example of inequitable delegation of accountability.  By not removing the additional citation after the dispute process ends in favor of the provider, per this guidance document, a licensing specialist can be wrong but the provider still gets punished for not going along with it (i.e. getting another citation that requires them to change policy and procedure and enact system changes that weren’t actually necessary). 

Removing the additional citation voids that issue entirely.