CAP includes systemic actions to ensure future compliance.  If this is a first time offense, how does that result in the need to be addressed systemically?

CAP includes means and processes by which evidence of completion of the CAP will be collected and provided to the Office of Licensing.  Will activities to support the CAP need to be submitted or be available if requested?

CAPs returned for a third time for not meeting minimum requirements will result in an additional CAP seems excessive and unnecessary.  If the provider is having difficulty in creating a CAP that does not meet minimum requirements, then OL should be providing coaching/education along the way for how this can be addressed.  Is this really a necessary item?