Why is it that the provider has very specific time requirements when responding to CAPS, yet there are no time frames for DBHDS to issue, review or comment on these CAPs?  If the issue is so serious as to require a citation on a provider, DBHDS should also be under specific time frames for their own accountability when issuing, reviewing or commenting on these citations.

Returned CAPs for “failure to meet all requirements within 12VAC35-105-170.C” adds a citation prior to beginning the dispute process outlined in 12VAC35-105-170.F, which is outside of the regulatory requirements in 12VAC35-105-170.E.  Provider is concerned about the Department’s approach of adding citations as a way to address concerns or simply a provider not agreeing with a Licensing Specialist.  This provider’s reading of the regulation this Guidance pertains to, does not have the adversarial feel this Guidance does.  Citations are a part of this business – no provider likes to receive them, and Licensing Specialists should not enjoy issuing them.  Again and again, providers are told that the Department and providers are intended to work together to provide quality services, yet there is a large discrepancy between statements like “work together” and a Guidance document that mandates outside of the regulatory requirements currently out for final comment up to 3 citations (and possibly a reduced License) for a CAP with a single citation that a provider disagreed with or a Licensing Specialist felt that the “systemic changes” did not go far enough and the CAP then went through the dispute process for.    

Another commentor asked the question which I will repeat - if a CAP goes through the dispute process and the Supervisor agrees with the Provider, is the 2nd(? 3rd?) citation removed?  Why would the provider be penalized if the Supervisor ultimately agrees with the CAP the provider submitted?

When providers should consider steps to writing a CAP, Department states to develop a “systemic plan of

action”, Provider can see instances where simpler solutions than “updating policies, procedures, forms, or

conducting training/retraining for staff” would resolve the issue.  As this provider commented on the final

regulations now out for comment, provider’s issue lies with the assumption that a fully implemented plan

would always prevent the recurrence of a violation, and that failure to do so requires a systemic plan – some

issues that are included on a corrective action plan may not be something that a provider can guarantee won’t

occur again regardless of the plan of action put in place.  This seems an impossible standard to meet.  As

another commenter noted, issuing additional citations 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.