We begin by assuming that it is the expectation that any regulated entity will comply with the regulations, however, it is also true that regulations are developed to set a standard that the State can rely on to provide assurance to the public, to the legislative body that appropriates funds for the purpose of supporting the regulated service and, if appropriate, to the Federal Government who may also provide support that they adequately protect their interests and enhance their mission.  If standards are so weak or enforced so poorly as to always be met, the latter function is not accomplished.

Therefore, citations for failure to meet a specific standard is the norm and not the exception. 

It is the structure of the system that the regulated entity will produce a Corrective Action Plan (CAP) for each citation in accordance with 12VAC35-105-170 A - C.  If the Licensing Specialist does not agree with the CAP, it is their responsibility to state clearly the reason for their disapproval.  For example,

1)  the corrective action does not comply with the standard cited, or

2)  the citation is either one which has been made before, or is made about multiple incidents and the corrective action does not address the larger issue.

The provider has a wide range of options in developing a CAP and retains the right to a wide range of actions which may be taken as a part of exercising good judgement and best practice which may or may not be included in the CAP.

The Specialist also has a wide range of options including follow-up visits or visits to other locations where the same issue may be present to monitor the performance of the provider.

The Guidance offered suggests two things:

First, the Office of Licensing, DBHDS, views all regulations equally critical and therefore all citations equally serious.  And,

Second, the Office of Licensing, DBHDS, will not accept the basic and rather obvious premise that the development and complete implementation of a corrective action plan will not prevent the recurrence of the occurrence of either human error or burned out light bulbs.  A perfect example of human behavior is found in this regulation:

12VAC35-105-170 C states that:

"The corrective action plan shall include a:

1. Detailed description of the corrective actions to be taken that will minimize the possibility that the violation will occur again and correct any systemic deficiencies"

12VAC35-105-170 H (added only for the final regulation) changes the meaning of the earlier section by adding that the corrective action is to "prevent recurrence of a regulatory violation" which is an entirely different construct. 

The Guidance should be withdrawn.