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Together Georgia Response to DFCS/DHS Proposals for Eliminating Administrative Burdens of Oversight*:

Together Georgia Issues and Recommendations

1. Issue – Disruption caused by unscheduled inspections

DFCS/DHS Proposals’ bullet 3 (a) and (b) states agencies will improve coordination of site visits when possible and suggests the creation of a universal calendar in Georgia Score to limit concurrent or consecutive visits. Proposal 2 (a) notes statute requiring annual licensing and inspections as a barrier.

Response: Together Georgia requests that creation and ongoing utilization of the universal calendar include provider input whenever possible for scheduling routine inspections/surveys. We also submit that this proposal does not reduce or eliminate existing inspections nor does the proposal address the request for announced annual or periodic inspections. In response to 2 (a), Together Georgia states that the statute requiring RCC to license and inspect annually should be changed and will provide wording for recommended statue revision.

2. Issue – Replication of oversight by state auditors from different divisions within Department of Human Services (DHS)

DFCS/DHS Proposals’ bullets 1(b) identifying streamlined reporting potential in Georgia Score and 4 (a)-(d)  defining barriers to more universal communication touch on the requested changes, but do not create a significant impact by decreasing the replication of oversight by DHS.

Response: Together Georgia presents the efforts of providers in North Carolina to address burdensome oversight through legislation presented at 2011 General Assembly of North Carolina entitled “Streamline Oversight/DHHS Service Providers” and recommends such a bill be adopted in Georgia. This legislative effort is paired with the flow chart entitled “Streamlined Oversight Process” and the creation of a centralized monitoring agency to encompass licensing, monitoring, contracts, audits, critical incident response, memorandum of agreements, certifications, investigations, credentialing reporting, enrollment and national accreditation status.

3. Issue – Reduce the number of unnecessary and repetitive citations by all regulatory agencies.

DFCS/DHS Proposals’ bullet 2(a)-(e) provide some adjustments to reduce “routine” inspections through the increase of utilization of information, but does not fully address the problem of multiple citations for single events/issues.

Response: Together Georgia requests that our original recommendations be considered. We also promote a streamlined oversight process (referenced in #2 issue above) be adopted through the creation of a centralized monitoring agency to adopt standards properly aligned to services, provide interpretive guidelines to reduce surveyor and provider misinterpretation, reduce  multiple and inconsistent citations , and eliminate the punitive oversight model.

4. Issue – Current RCC website list of agencies’ inspections is often misleading, not updated, and sometimes unfairly written.

DFCS/DHS Proposals do not address this issue.

Response: Together Georgia alters the request to eliminate the website in lieu of clear reporting and prompt updating and maintenance of the site and reflecting final findings after the provider opportunity of a fair and effective appeal process.

5. Issue – The Current appeals process is lacking.

DFCS/DHS Proposals do not address this issue

Response: Together Georgia continues to recommend improvement in the refutation of citation/appeals process to include an objective, independent, review procedure.

6. Issue – Improve communication, follow-up, accountability of regulatory body and improve consistent interpretation of standards.

DFCS/DHS Proposals’ bullet 4 (a)-(d) supports continued multi-agency oversight and inspections and does not propose methods to improve communication or regulatory agency accountability for prompt, effective responses or surveyor interpretation.

Response: Together Georgia maintains the original recommendations and suggests creation of a centralized monitoring agency (referenced in Issue # 2 above) to improve surveyor interpretation of standards and reporting accountability.

7. Issue – Many regulations unrealistically impact healthy, age-appropriate normalcy for children in care.

DFCS/DHS Proposals do not address this issue.

Response: Together Georgia maintains its recommendation to align regulation with policies and practices that encourage age appropriate normalcy of care for children and families. The creation of a centralized monitoring agency (referenced in issue #2 above) would allow for the opportunity to appropriately align standards to services and provide greater consistencies for surveyor and provider interpretation of standards.

* We numbered and lettered the DHS proposed bullet and sub-bullets in order to better communicate our response.

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Feedback to the HR 1723 House Study Committee

HR 1723 is an important and vital effort to review the  process for licensing of private child welfare providers in terms of effectiveness, unnecessary state interference, acknowledging and taking  advantage of  providers with strong records of quality performance and minimizing duplicative or  burdensome requirements by state agencies.  The committee established by HR 1723 is tasked with studying these issues and recommending appropriate legislative or agency action.

This occurs during the intense focus on child safety initiated by the General Assembly and the Governor.  All discussions should occur in this context and never compromise Georgia' ability to protect its children and garner new resources for that goal.  Some oversight issues can be appropriately examined at the same time to make sure the operation of Georgia's foster families, homes, community services and facilities are enabled to help their children more effectively.

The Department of Human Services ("DHS" or "Department") has the authorization to regulate child welfare agencies under O.C.G.A. § 49-5-8 and O.C.G.A. § 49-5-12.  The Department administers procedures, standards, rules and regulations established by the board or required by grants it receives.   Therefore, the DHS board has the power and ability to modify or change many of its rules and procedures.

In response to HR 1723, Together Georgia formed a work group, made up of Child Placement ("CPA") and Child Caring Institutions ("CCI") organizations, to review their experiences with current regulatory oversight and develop recommendations for the study committee.  These agencies share a belief and commitment that appropriate and effective oversight is necessary to ensure the safety and wellbeing of children in the care of private provider agencies.  These discussions included the impact of the regulatory process on:

• Delivery of services

• Resources

• Program Development

• Normalcy

• Funding

• Communication

Together Georgia, 50 Hurt Plaza, Suite 155. Atlanta, Georgia 30303

ISSUES AND RECOMMENDATIONS

1. Issue - Disruptions caused by unscheduled inspections.

Examples: 

• Foster parents receive home visits from the following agencies:  DHS Office of Provider Management ("OPM"); DHS Residential Child Care ("RCC"); DHS County Division of Family and Children's Services ("DFCS") Case Managers; and Private Agency Case Managers. Foster homes have experienced occasions where RCC and OPM perform an unscheduled visit on the same day; even though the records investigated by each entity are the same.      

• Provider agencies' staff members at facilities are pulled away from responsibilities to respond to unscheduled visits.  Inspectors have shown up unannounced when the appropriate staff are not at the provider agency’s site.  (One provider agency was given a citation for non-compliance even when appropriate staff members were available later in the day.)

Current Same Rule Section(s) Referenced:  See Rule 290-2-5-.07 (CCI) and Rule 290-9-2-.11 and 290-9-2-11  and (CPA)

Also, at p. 5 of the FY 2014 Room, Board and Watchful Oversight Minimum Standards for Child Placing Agencies and Child Caring Institutions (Office Provider Management ("OPM"):  "The Standards are intended to be qualitative, in that they provide a tool for judging the quality of care provided and are also designed to be measurable. The Office of Provider Management (OPM) will monitor providers against these standards during its annual comprehensive reviews and through randomly occurring Safety Reviews.  During monitoring visits, OPM will look for evidence that the requirements are being met. Provider practices which exceed the requirements of the Minimum Standards will also be identified and documented in the OPM monitoring report."

Recommend: Change the requirement for having unscheduled annual regulatory audit inspections to scheduled visits for this purpose.  Limit unscheduled visits to those that are in response to actual safety reports.

Rationale: Unscheduled visits require extensive information to be pulled together and staff members to be available to respond to the inspections. Scheduled appointments for these inspections would enable agencies to do the focused work necessary in the time frame surrounding the inspection and ensure that the appropriate staff and resources are available to the surveyor while also maintaining appropriate supervision of youth and without further disruption to the agency’s programs. Many states currently allow for scheduled annual inspections.

2. Issue - Replication of oversight by state auditors from different divisions within Department of Human Services (DHS).

Examples:

• Provider agencies undergo inspections by different DHS divisions. OPM, RCC, and Kenny A auditors all came to one provider agency during the same two-week period.  In several cases, two inspection teams examined the same files.   

• RCC requests copies of home studies and related documents that already have been uploaded into the DFCS’ SHINES system and GA Score system. 

• RCC audits focus on contract performance (duplicating OPM) and miss critical agency governance issues. 

Current Rule Section(s) Referenced:  See  Rule 290-2-5-.07, Child Placing Institutions; Rule 290-9-2-.11, Child Placing Agencies concerning inspections.  See also FY 2014 Room, Board and Watchful Oversight Minimum Standards for Child Placing Agencies and Child Caring Institutions (Office Provider Management ("OPM").

Recommend: Eliminate replication of oversight and accentuate data sharing whenever possible. Permit consideration of nationally accepted accreditations, Council on Accreditation (COA), Joint Commission on Accreditation Healthcare Organizations (JCAHO) or Commission on Accreditation of Rehabilitation Facilities (CARF) as evidence of state compliance.

See   , and

Rationale: When public or private provider agencies are required to produce the same information on different occasions for different divisions of the same department, their administrative costs increase. This consequence shifts funds and resources away from direct care of the children. It would be more efficient if these inspections were combined or reduced in scope with the synchronizing of requirements and sharing of data and reports.

3. Issue - Reduce the number of unnecessary and repetitive citations by all regulatory agencies.

 

Examples:

• Provider agencies are cited for incidents that occurred at the child’s home.

• Absence of recognized standard for adults- to- child ratio results in many incidents cited as “lack of supervision.”

• Provider agencies are cited multiple times for single incidents under each separate citation.  The provider agency corrective action plans are the same for each criterion. The multiple citations create unnecessary work and an inflated record of citations.

(examples cont.)

• Provider agency was cited for lack of supervision when a teen parent was hit by a ball in a church fellowship hall and dropped her baby, while the agency personnel retrieved their jackets.

• Provider agency was cited for being one day late on physicals although insurance will not pay for the physical if such examination is conducted sooner than one year - it has to be one day later than the last physical.

• While employer (provider agency) takes appropriate action involving a wrongdoing of an employee, that same provider agency is still cited for an incident although the employee had been appropriately reprimanded and/or dismissed.

Current Rule Section(s) Referenced:  Multiple rules apply including investigations, staffing and others.

Recommend: Provider agencies propose the following ideas:

(1) Limit citations to what is material to the safety and well-being of the child.

(2) Move from punitive approach to one that better evaluates scope and severity of an incident.

(3) Develop appropriate licensure category to capture realities of “specialty programs,” such as the family based model, rather than considering all programs the same.

Rationale: The existing process is based on a punitive model, which may be appropriate if there is a question regarding child safety issues.  It would be a better model to encourage the development of quality care providers or assist providers who want to help children develop normally.  Many provider agencies report the tendency for RCC to give citations when fair judgment would agree they are not necessary. A one-time incident or occurrence, a “one-off,” that is not harmful to the safety or wellbeing of a child is different than a pattern of behavior.  Creating a way to make note of an incident without a citation could suffice in these areas.

4.   Issue - Current RCC website list of agencies' inspections is often misleading, not updated, and sometimes unfairly written.    See: . This same information is also available through the Department of Community Health ("DCH"), Healthcare Facility Regulation, website .  

Examples:

• Provider agency annual inspection was conducted during Christmas holidays when the family based program was closed and children were not in residence. Some of the citations posted online were minor and occurred during a period of time when only staff and their families were present in the home.

• Private funding support was withdrawn from provider agency due to reports posted online.

• Multiple citations for single incidents create inflated citation numbers and reflect negatively on a provider agency.

Current Rule Section(s) Referenced:   See Rule 290-2-5-.19 (3) (f): "The Department may post an official notice of the revocation or emergency suspension action on its website or share the notice of the revocation or emergency suspension action and any information pertaining thereto with any other agencies that may have an interest in the welfare of the children in care at the institution."

Recommend:  Eliminate current website posting of deficiencies prior to plans of correction or final actions.

Rationale: The website reflects citations which may distort a provider agency’s status, thus hurting the provider agency’s reputation. Multiple citations can be listed for a single issue. The “findings” are posted often out of context or are misleading.  Further, they are posted prior to any appeal process that may occur. The website is often not updated in a timely manner to reflect changes in response to subsequent corrections and/or appeals.  This can have a negative impact on potential charitable funding sources who significantly contribute to the cost of providing services to children.

5.   Issue - The current appeals process is lacking.  

Examples:

• Although provider agencies are given opportunity to refute citations, they are reviewed within the same Division and seldom overruled.

• An agency appeal was ruled in favor of the provider agency by an appeal review attorney, only then to be overruled by the Department.

• When a foster parent made an error in judgment and was prosecuted, the provider agency was cited for lack of supervision because the foster parent was evaluated as an employee of the provider agency.  The administrative hearing officer ruled in favor of the provider agency in regard to any negligent oversight, but DHS overturned the hearing officer's findings.

Current Rule Section(s) Referenced:  See Rule 290-2-5-19 (1) and (2) Enforcement and Penalties (Child Caring Institutions):  "(1) Plans of Correction. If the Department determines that either a child-caring institution or a facility applying to become licensed as a child-caring institution does not comply with the rules, the Department shall provide written notice specifying the rule(s) violated and setting a time for the institution not to exceed ten (10) working days within which to file an acceptable written plan of correction where the Department has determined that an opportunity to correct is permissible. If such plan of correction is determined not acceptable to the Department because it does not adequately correct the identified violation, the Department will advise the child-caring institution or facility applying to become licensed that the plan of correction is not acceptable. The Department may permit the institution to submit a revised plan of correction.

(a) The institution shall comply with an accepted plan of correction.

(b) Where the Department determines that either the child-caring institution or the facility applying to become licensed as a child-caring institution has not filed an acceptable plan of correction or has not complied with the accepted plan of correction, the Department may initiate an adverse action to enforce these rules.

(2) All adverse actions to enforce the Rules and Regulations for Child-Caring Institutions shall be initiated in accordance with the Rules and Regulations for Enforcement of Licensing Requirements, Chapter 290-1-6, and O.C.G.A. §§ 49-5-12 and 49-5-12.1, Penalties for Violation of Child Welfare Agency Laws and Regulations and § 49-5-60 et seq. and the requirements set forth herein."

See also Rule 290-9-2-.14, Enforcement and Penalties for Child Placing Agencies.

Recommend: Improve refutation of citation/appeals process to include an objective, independent, review procedure.

Rationale: The current appeal process, often without recourse, can be time consuming and expensive. An outside reviewer is needed to provide objectivity.  The Department should not be the last resort when it comes to reviewing the decisions of its own workers when being contested by a private provider agency with professional staff weighing in with contrary perspectives. Further, there is no outlined formal appeal process for a Child Placing Agency.

6.   Issue - Improve communication, follow-up, accountability of regulatory body and improve consistent interpretation of standards.  

Examples:

• Inconsistency between RCC inspectors regarding the interpretation of standards.

• Some current standards are vague and require explanation and/or interpretation prior to holding agencies accountable.  

• Inspectors sometimes leave an inspection without input from the provider.

• Delays in provider agencies receiving findings/feedback from inspections development of corrective action plans are delayed in being submitted.

• Limited opportunity for provider agencies to evaluate the inspection process and inspectors.  

Current Rule Section(s) Referenced:  See Rule 290-2-5-.19 (1):  Listed above in Item 5. See also Rule 290-9-2-.14, Enforcement and Penalties for Child Placing Agencies.

Recommend: Provider agencies make the following four suggestions:

(1) Maintain updated interpretive guidelines manual and train inspectors to these guidelines.

(2) Provide exit review with providers in all cases.

(3) Develop a clear and standardized time frame for RCC to respond to findings and agencies to submit corrective action plans.

(4) Utilize evaluation tool for feedback/evaluation of inspector’s work.

Rationale: Consistency is needed in interpretation of current standards in order for provider agencies to have clarity on requirements. Likewise, such clarity and consistency are needed for inspectors to accurately determine violations. Provider agencies need the opportunity for an exit review conference in which findings can be addressed while the inspectors are still on the premises. This interview would allow for possible immediate correction of unnecessary citations, such as when requested information is available in records not reviewed. Provider agencies also should be able to evaluate an inspector following his/her visit, thereby creating a mechanism to identify inconsistencies or patterns.

7. Issue - Many regulations unrealistically impact healthy, age-appropriate normalcy for children in care.  

Examples:

• Provider agencies are required to take from youth various articles such as shampoo, toothpaste, deodorant and hair spray, place in a locked cabinet, even in non-therapeutic family based programs serving adolescents.  

•  Provider agency was cited for lack of supervision when foster care brothers were shooting hoops in a pick-up game initiated by other children (the brothers were permitted to be outdoors even though each had dialysis ports for their health issues).  There was a physical injury in the hoops game, but the brother was appropriately taken to an emergency room and was released after treatment. The foster brothers were engaging in normal teenage behavior which would essentially develop their socialization skills.

Current Rule Section(s) Referenced:  See Rule 290-2-5-.18(9):  "The institution shall be kept clean and free of hazards to health and safety and of debris and pests."  Further at Rule 290-2-5-.18(9)(b), it requires, "An effective pest control system shall be implemented.  Pesticides, disinfectants, chemicals, and cleaning supplies, with hazardous labels, shall be stored in designated areas away from children and if used by children, such use shall be supervised by staff."  See also Rule 290-9-2-.07(5)(9)(ii)(VIII) which requires that "hazardous items are not accessible to children."

Recommend: Align regulation with policies and practices that encourage age appropriate normalcy of care for children and families.

Rationale:  Normal home-like conditions promote youth being able to grow up and take on age appropriate responsibilities.  Of course, safety considerations are paramount and need to be evaluated to ensure a child’s well-being.

The standards/rules may be found at:

Office of Provider Management (OPM), RBWO Minimum Standards –



Regulatory Child Care (RCC) Child Caring Institution ("CCI") License –



Child Placing Agency ("CPA") License –



Healthcare Facilities Regulation, Residential Mental Health Facility ("RMHF") License –



Psychiatric Residential Treatment Facility ("PRTF") Manual –



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HR 1723 Resource Material - National Perspective: Accepting National Accreditation as a Deemed Status

Feedback from Executive Directors of State Associations that are members of the National Organization of State Associations for Children (NOSAC) on the question, has your state incorporated the providers’ national accreditation (COA, JCAHO, CARF) into how licensure practices are conducted and has any of your states undergone revisions to licensure/regulatory rules recently? If so, could you please share them with me and if the changes have improved the system or not?

Kentucky - Does require accreditation as part of their residential or foster care license, however the state does not allowed any type of deemed status.  They still get annual licensure reviews, in addition to their accreditation.

Pennsylvania - Does not. They have a long history of avoiding recognition of accreditation as an option for relief from regulatory reviews – they keep raising it but it consistently meets with pushback.

Indiana - Only has deemed status for the Psychiatric Residential Treatment Facilities (PRTF) through Medicaid certification, but not for licensure by the Dept. of Child Services.  They are working on that with DCS and COA, but it is still in the early stages.  COA will do a crosswalk for your state of the licensing regulations as compared to the accreditation standards that they uphold. 

Wisconsin – Does not have any recognition of COA in the child welfare arena.  It is recognized in child care.  In administrative rule they have a requirement that the Department of Health Services should recognize it in terms of re-licensing of outpatient clinics, but DHS is not implementing the provision.  COA says Wisconsin is the exception in terms of their being able to work with states on this. 

Colorado – none

South Carolina - Does not forgo annual inspections for accredited providers.  Licensing standards have not been revised in years.

North Carolina - The state had a bill passed that directed DHHS to identify any duplications of the state system national accreditation in an effort to streamline the process and according to sources DHHS did not comply. They had another directive language in a reform bill this session (2014) that missed being passed in the last week. It is reported that NC State staff have an incredible lack of confidence in the quality related to national accreditation because they (and the FBI fraud unit) have rooted out really, really bad providers who were in good standing in their accreditation (CARF in particular).

The duplication of licensure/regulatory requirements has been a hot button issue for about six (6) years because of a DHHS policy change that required providers to be nationally accredited to provide Medicaid services. Providers have repeatedly raised the question as to why DHHS want them accredited if they do not actually believe it has value. The requirement is now in state rule and in the Medicaid SPAs.

New Jersey - This is something they have been working on for many years.   They report making some progress and then the lead person at the department left and things have slowed down.  The state is technically in the middle of a pilot program which would do exactly what we inquired about- alleviate the burden of duplicate survey visits. Attached is the NJ pilot program description and a Powerpoint describing the project.  Here is the most recent update from our department:  The department is now calling the project “Recognition of Accreditation” pilot. There were 10 participating partial care programs and the process is still ongoing. When completed the department will evaluate the results and make further decisions.  The first modified inspection of a pilot project participant was conducted in May 2013. As fewer items were being inspected, the time taken to complete the on-site inspection was shorter, which was one of the targets of the project. Prior to the pilot inspections for Children’s Partial Care took an average of three (3) days to complete. During the pilot, inspections take an average of two (2) days to complete. As of the end of February 2014, 6 of the 10 pilot project participants have received a modified inspection and all were of shorter duration. The final 4 modified inspections will be conducted by the end of the pilot project in August 2014.

   

 Minnesota - Tried many years ago to get deemed status with the same response from our licensing division (no trust in accreditation).  They do not have the accreditation requirement in MN – They report having excellent, frequently reviewed, services.

California - None, although not for lack of trying.

Massachusetts - None – every year, every program has their EEC licensing come and check them annually.

Michigan - Michigan has not recognized accreditation in its licensing process.  They have been working on this for a number of years (seven). As they move in a stronger way toward their performance based child welfare system, the issue of deemed status is something their association is pushing again. Several years ago, the state licensing did a pilot with only one or two of their agencies, where accrediting requirements were taken into account with several audits, and it worked very well but did not go any further.

New York - There is no recognition of accreditation.    Only deeming is that PRTF'S licensed by New York mental health agency must be accredited.    .

Maryland - PRTFs are required to be accredited by the Joint Commission and are the only children’s programs that have deemed status. Over the past 20 years Maryland has had many discussions with state agencies and introduced multiple pieces of legislation without success.

Illinois – They are implementing Deemed Status for a number of licensure/certification rules. For child welfare, there are certain licensure provisions for child welfare agencies that are considered "met" if the agency is COA accredited. That reduces somewhat the extent of licensing inspections. In their Medicaid program, certain elements are deemed met if the provider is JCAHO accredited. They have had deemed status on the books in child welfare for 15 years or so without implementation guidelines. They report still having a ways to go to move towards acceptance of other accreditations and review of a number of other rules, but it is a start.

Louisiana - In Louisiana some services are eligible for deemed status: PRTFs, Therapeutic Group Homes (TGH) (Some of the TGH requirements have changed; however deemed status remained), Home and Community Based Services (HCBS Waiver) requires completion of an application and $25 application fee, and Substance Abuse /Addiction Setting (24-hour facility, opioid treatment program)

 

It is reported that HCBS providers often get visits from surveyors, but they show them their letter from the DHH stating that they have deemed status, and the surveyors go on to their next site. Because TGHs are new to Louisiana, they do not have any history yet to know how well the deemed status will work for them. In the past two years they have been successful in getting the rates for TGHs increased from a bundled rate of $202.80 to $243.32. 

Tennessee – Has not been able to forgo Licensing’s annual review, but they have gotten Children’s Services to forego PAR (Program Accountability Reviews) on the years that a provider undergoes accreditation.  In order to contract with Children’s Services in TN a provider must be accredited.

Ohio - Has deemed status for mental health and AOD program certification (CARF, COA, and Joint Commission).  They are building a deemed status program for child welfare (foster care, residential, adoption, independent living) certification with the same three accrediting bodies. 

According to the U.S. Department of Health and Human Services National Review of State Alcohol and Drug Treatment Programs conducted in 2003 (most recent I could locate) the following states answered “yes” to the question, “Does the State Accept Accreditation Through National Accrediting Organizations in Lieu of Accreditation by the State?”:

Arkansas, Arizona, California, Connecticut, Florida*, Idaho, Illinois, Iowa, Kansas, Maine, Maryland, Michigan, Mississippi, Minnesota, Montana, Nebraska, North Dakota, Ohio, Oklahoma, South Dakota, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming.

* Florida accepts accreditation through the Joint Commission, CARF, COA and NCQA for programs other than opioid treatment programs. For opioid treatment programs, Florida accepts accreditation through JCAHO and CARF. However by law Florida retains the authority to conduct an on-site licensing inspection of all accredited substance abuse providers every three (3) years. All substance abuse programs must be licensed annually.

Response from COA: COA is recognized as an approved accreditation in all states except Texas, Mississippi and New Hampshire.  Our current recognition report can also be searched by service area or type (like mandate) on their website,

Attached is a recent COA recognition report.  On the COA staff are Joseph Seoane (JSeoane@) or Jaclyn Greene-Stock (Jstock@).

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