Requiring CAPS to address systemic plan of action for problems identified does not take into account that there are individualized events that occur that do not require systemic level corrections.

The process to submit signed CAPS is not effective with the technology available to most agencies in collaboration with their licensing specialists.  Signed CAPS have to be sent as PDF's. Licensing specialists request that the CAPS be submitted as word documents so they can identify if the action plans are approved.  Once they are approved by licensing, a signed CAP can be sent back as a PDF.  That system does not align with your guidance.

Guidance that an additional citation will be issued if a CAP is returned to a provider for a third time for failure to meet all requirements is concerning.  Issuing a CAP during this process is punitive rather than collaborative.