Please do not assume any lack of response to the 29 pages released in this group of memos is due to lack of concern from the provider community. Providers have for several months been stretched to the breaking point by the pandemic. Providers have been trying to keep individuals and staff safe while staying in business. This set of memos, this one in particular, are extremely important and critical to the viability of the provider community. This is being pushed through during a state of emergency when many are focused on current community health risks and concerns. The fact that any agencies are taking time away from trying to keep people safe and stay in business should raise the awareness of DBHDS to the concerns being noted about this memo.

The information in this document is a substantial change for the provider community and places additional burden upon providers. This memo crosses over into regulating through guidance.

Timely reporting is necessary and agencies need internal systems for improvement. However punishing providers for reporting on the 27^th hour or updating within CHRIS on the 50^th hour may result in providers making the decision to not report and take a chance on it being found in a review, especially when reporting in the 27^th hour and a non-reported incident identified in a review receive the same response. Providers who report in that 27^th or 30^th hour are the providers you want to work with and encourage to grow and improve, not discipline. This is something a CRC in Provider Development could help with instead of punishment by a licensing specialist or someone with the IMU. There have been some recommendations to move this to business days vs calendar days which could prove beneficial and decrease the risk of losing providers who are working to report and be in compliance.

The steps of progressive discipline, up to and including denial of license renewal, issuing a provisional license and revocation or suspension of a license for the 4^th citation within a two year period presents multiple concerns that have already been expressed by many in this forum.

1. No CAP can absolutely guarantee that it will Prevent another occurrence. We are dealing with human beings. This needs removed and replaced with “mitigate the risk”.
2. Once a citation and CAP is in place, if another violation occurs the citations grow exponentially the way this is written. If a provider follows the plan everyone agreed to and it does not work, it is time to try something else. It is not time to issue another citation for a plan that a provider implemented but did not work.
3. Nothing in the Progressive Action section seems to take into account number of programs, locations, regions of the state (different specialist interpretations) or size of the agency. This has to occur.

In sponsored residential a provider agency may have hundreds of contracted homes. A group home provider may have dozens of sites with different managers in those homes or regions. Agencies may also operate group day or any of a number of other programs. An issue within one program, one region or one home/site may be just that, an issue within one program. If that is the case it should not impact the entire agency but only that specific residential location, service site or program. This memo does not appear to take any of that into consideration or allow for varying responses on the part of licensing based on the information they receive.

This Guidance document needs to be pulled and reworked with additional input from stakeholders.