General Comment:

Southside Community Service Board complies with regulatory requirements. As DBHDS expectations and requirements burgeon across all of its departments, it is increasingly challenging to meet requirements with current staff. Southside Community Service Board is requesting consideration of funding for additional administrative and/or quality assurance staff to meet expectations. Consideration is also requested for DBHDS to partner with providers in the drafting of future regulations and guidance documents prior to the public comment period to gather input on implementation impacts.

Guidance Document:

12VAC35-105-170. Corrective action plan.

H. The provider shall monitor implementation and effectiveness of approved corrective actions as part of its quality improvement program required by 12VAC35-105-620. If the provider determines that an approved corrective action was fully implemented, but did not prevent the recurrence of a regulatory violation or correct any systemic deficiencies, the provider shall:

1. Continue implementing the corrective action plan and put into place additional measures

to prevent the recurrence of the cited violation and address identified systemic

deficiencies; or 2. Submit a revised corrective action plan to the department for approval.

Comment:

I do not disagree with the idea of monitoring the effectiveness of approved corrective action plans or submitting a revised corrective action plan should the corrective action plan not appear to be effective.  My 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.