Comment on Guidance on Corrective Action Plan

It appears that the guidance document referencing corrective action plans continues to implement additions to the regulations in place, in what appears to be the implementation of additional regulatory requirements through a guidance document versus an update to the existing regulations. This causes some confusion in that the guidance document should be to elaborate on the regulations to aid in clarity and further understanding. The way in which these guidance documents are outlined results in additional confusion and misunderstanding regarding the regulations at hand. Having this guidance document outline the regulations in a usable manner would be recommended without additional information beyond the outlined regulation being referenced. This includes reference to details pertaining to additional citations being provided for failure to meet all requirements within regulation 12VAC35-105-170; however, the guidance outline offers additional requirements than referenced within the regulation.

Additional language utilized within the guidance document should be removed, as the wording remedying and preventing the recurrence of identified regulatory violations; however, the regulations define corrective action plan as the Provider’s pledged corrective action in response to areas of noncompliance. The wording within the guidance document is not a realistic expectation of Providers to prevent occurrences of violations. Providers from across the state would like to ensure the prevention of many occurrence that unfortunately take place; however, in working with the reality of service delivery this is not a standard that can be upheld.

Additionally, this guidance document continues to note the intent of the department to move forward with progressive action steps that continue to be outlined within the use of language such as the issuing of additional citations. There is also a notation that if the Provider reaches out to a Specialist’s supervisor that this would be referred back to the Specialist which does not provide a point of remedy for potential issues that may surface regarding interpretation of regulations and CAPs, as essentially there is no ability for the Provider to seek additional support to address areas of concern with the involvement of other staff members.

Thank you for your time and consideration.