We appreciate efforts to standardize and publicize expectations regarding the content of CAPs and recommend revising the CAP form to promote successful fulfillment of the expectations, which benefits both the Office of Licensing and providers.  While we understand the importance of including systemic corrections, the expectations allow no latitude for the reality that some events are idiosyncratic and do not require a systemic level correction.   Please specify the timeframe allotted to Licensing Specialists to send a CAP to a provider and to review and follow up with providers after a CAP is submitted.

We are concerned regarding the plan to issue an additional citation “if a CAP is returned to the provider a third time for failure to meet all requirements”.  While the guidance document recognizes the need to initiate the dispute process, the concurrent issuing of a citation presumes the issue at hand is one of noncompliance with 170.C vs. another factor and presumes an unwillingness to collaboratively problem solve.  The additional citation under 170 C should only be issued, if indicated, after the dispute resolution process has completed. 

Please be aware that there is a frequent disconnect between current practice and the regulation 170.C.3.  It is not unusual for providers to be asked to defer signature on the CAP until it has been approved.  To avoid unnecessary citations, please ensure all Licensing Specialists accept that providers will need to sign CAPs upon initial submission and after any revision.