Here are some things to consider in determining whether the problem is discrete or systemic:

• What is the agency's process for communicating reporting parameters to clinical staff?
• How do clinical staff learn of reporting parameters?
• Do they have access to reporting parameters at the time of the visit?
• If there is a pattern of clinical staff not being aware of reporting parameters, how could the agency modify its systems to ensure that the right staff have access to the right information at the time of service delivery?