12VAC35-105-170. Corrective Action Plan (C)

The draft Guidance indicates the provider should “develop a systemic plan of action to address each problem.” We object to this language as it makes an assumption that every violation cited by the Department will be systemic in nature and require a systemic solution. For providers with multiple programs the solution for the issue in one program may not be relevant to another program. To require a systemic plan for every problem has a potential to create new issues within programs that may not have the same structure as the program the plan of action is intending to address. Furthermore, some issues may have simple solutions that do not require policy, form, or procedure changes. DBHDS should consider modifying the language to reflect that not all issues identified are systemic and not all issues require complex solutions.

The regulations also indicate the provider will “[detail] actions taken that will minimize the possibility that the violation will occur again.” The guidance provided by DBHDS is silent as to what standard Department will utilize when measuring whether the corrective actions taken will minimize the possibility that the violation will occur again. We ask that a uniform standard be developed in order to ensure implementation of CAPs for providers across the state can be consistent. A communicated standards for “minimalizing risk” will not only provide for the safety and wellbeing of the individual served but provide ease of correction for each provider.