Action | Three Waivers (ID, DD, DS) Redesign |
Stage | Final |
Comment Period | Ended on 3/31/2021 |
132 comments
12VAC30-122-390 includes language which appears to be a substantive addition and revision since the publication of this section in the “proposed stage.” The language restricts the number of licensed beds in a setting reimbursed for group home residential to 6 (six) or fewer. We do not support large congregate settings, however, we are mindful that the level of support needed by individuals in any size home is dependent on many factors out of the immediate control of the provider. Those factors include;
Providers have experienced years of rate stagnation while trying to accommodate the rising costs – the only remedy has been to increase the number of operating beds in the home to gain some economy of scale – the only alternative is to close the home and remove an option for community living. Since 1990, the Code of Virginia at §15.2-2291 has supported Group Homes of 8 beds of fewer by classifying them as “single family residences.” To impose a regulatory limit that is more restrictive is both short-sighted and unnecessary.
The rate structure, which makes smaller homes financially more practical, has brought down the number of people living in a home as it was intended to do, without imposing a top limit.
Therefore, based on the fact that imposing a restriction which limits a provider’s ability to conduct business in “final” regulations and limiting the opportunity for comment by affected parties:
We object to the inclusion of this provision as a substantive change not previously reviewed as part of public comment, however, recognize that requesting further opportunity for comment is unlikely to change the outcome. We will strongly request modifications of the language in the Manual to mitigate the most damaging impact.
12VAC30-122-390 includes language that restricts the number of licensed beds in group home residential to six (6) or fewer. CRi does not support large congregate settings. We have made a concerted effort over the past few years to reduce the number of individuals who reside in homes operated and supported by CRi. However, we are mindful that the level of support needed by individuals who reside in these homes is dependent on many factors one which impacted by reimbursement rates paid by Medicaid which are controlled by the General Assembly. Reimbursement rates have been stagnant for many years and the only remedy for providers has been to increase the number of operating beds in the home to gain some type of economy of scale. The current Code of Virginia classifies group homes of eight (8) beds or fewer as single family residences.
CRi does not support the inclusion of this provision. We strongly urge modification of the language in the Manual.
Region 2 Developmental Services (DS) Directors appreciate the opportunity to comment on the Waiver regulations and recognize the tremendous amount of work DMAS has invested in the updates. We are requesting reconsideration of two timeline components for slot assignment notification and acceptance defined in 12VAC-30-122-80. The two components are listed below:
Some of the challenges of implementation of the regulations as stated for each of these components are outlined below.
A. The support coordinator shall notify the individual and family/caregiver of slot availability and available services within the offered waiver within 7 calendar days of the waiver slot assignment date.
The proposed timeline of 7 calendar days does not provide CSBs adequate time for the administrative activities that must occur for individual/caregiver notification. Once slots are assigned CSBs, must go in and review the information and manually fix errors. Additionally, the slots are often assigned in large groups, with between 40-150 slots at one time. After the CSB is notified the slot has been assigned and reviewed the list for errors, a support coordinator is assigned to initially begin working with the individual/caregiver. Then a packet of information is developed to share with the individual/caregiver to ensure appropriate information is provided. This process takes time and 7 days does not sufficiently give time for the CSBs to complete the tasks. We would recommend (1) at least 15 business days are allotted for individual/caregiver notification after the waiver slot is assigned. (2) A process by which CSBs can request more time for notification if needed.
B. The individual/caregiver will confirm acceptance or declination of the slot within 15 calendar days of notification of slot availability.
In our experience, individuals/caregivers often require more than 15 days to accept/deny. Individuals/caregivers have questions and concerns they want addressed as they make the decision. The Priority 1 criteria states that individuals/caregivers agree to accept the waiver services within 30 days. We recommend individual/caregiver be provided 30 calendar days to confirm acceptance or declination of the slot once notified of availability.
Additionally, we request information on how the Support Coordinator/CSB are to proceed if the individual/caregiver has not made a decision within the specified time period. What are the responsibilities of the CSB/Support Coordinator and what appeal information needs to be provided to individual/caregiver?
Thank you for your consideration of our recommendations and requests outlined above. We are happy to provide additional information and can be reached by contacting, Lisa Snider, our Region 2 DS council chair, at lisa.snider@loudoun.gov.
on C 5b. Initital requests can only be authorized for 180 days:
There are times when it takes up to a month for ISARs to be approved. This can be even longer if the ISAR is pended (we can't start a service until final approval, so being able to bill retroactively does not help). In addition, if the staff or family has not been fully cooperative and we do not get data forms or they miss appointments, this causes another delay. Please keep authorizations at one year (or the duration of the ISP year).
On C. 5c, plans will be submitted with baseline data and quarterly data: There are many times we do not receive any data and other times we receive only partial data. At times, progress is anecdotal or evidenced by lack of emergency or crisis. For example, we may not received data but the person receiving the service has not been referred to emergency services or REACH centers. Please consider changing this to data or reports by staff and family.
Fairfax- Falls Church CSB agrees and supports all other comments to the date additionally to the below:
The proposed timeline of 7 calendar days as defined in A does not provide CSBs adequate time for the administrative activities that must occur for individual/caregiver notification. Once slots are assigned CSBs, must go in and review the information and manually fix errors. Additionally, the slots are often assigned in large groups, with between 40-150 slots at one time. After the CSB is notified the slot has been assigned and reviewed the list for errors, a support coordinator is assigned to initially begin working with the individual/caregiver. Then a packet of information is developed to share with the individual/caregiver to ensure appropriate information is provided. This process takes time and 7 days does not sufficiently give time for the CSBs to complete the tasks.
Recommend :
? requesting reconsideration of the timeline components for slot assignment notification:
? at least 15 business days are allotted for individual/caregiver notification after the waiver slot is assigned.
?A process by which CSBs can request more time for notification if needed.
Individuals/caregivers often require more than 15 days to accept/deny. Individuals/caregivers have questions and concerns they want addressed as they make the decision. The Priority 1 criteria states that individuals/caregivers agree to accept the waiver services within 30 days.
Recommend:
? reconsideration of the timeline components for slot acceptance.
?individual/caregiver be provided 30 calendar days to confirm acceptance or declination of the slot once notified of availability.
?requesting to add information on how the Support Coordinator/CSB are to proceed if the individual/caregiver has not made a decision within the specified time period. What are the responsibilities of the CSB/Support Coordinator and what appeal information needs to be provided to individual/caregiver?
“Progress notes” iii is signed and dated on the day described supports were provided.
The adjusted regulatory language requires that the provider complete all documentation on the same day of service which places an additional administrative burden on the staff, potentially limiting the number of services provided each day, reducing flexibility with services to adjust to the individual need. Recommend:
?Allow at least 24 hours to input the documentation of the service provision.
Recommend:
?Include links that will direct to the mentioned regulations.
Recommend:
? Define 90 days i.e., calendar or business days.
The content is referring to the Elderly or Disabled with Consumer Direction and the Technology Assisted waiver
Recommend:
? Update language- both Waivers are not currently available.
Recommend:
? Define “quarterly” and include 30 days grace period for its completion by the Support Coordinator.
Recommend:
? clarify “Risk Assessment” and change the wording to the Risk Awareness Tool as currently the Risk Assessment is only completed with SIS completion and not during the annual person- center plan review.
The Board offers the following recommendations to improve and clarify the DD Waiver regulations, organized by regulatory citation. The comments focus on 1) Instances in which the Town Hall Regulatory Background Document: Appendix A states that the change/edit was made but the regulations don't reflect the change, 2) Identified errors in the regulations, and 3) Comments on the service Peer Mentor Supports.
12VAC30-122-20. Definitions
Comment: Response indicates change was made, but the regulations do not reflect the change.
12VAC30-122-120 Provider Requirements
Comment: Response indicates change was made, but the regulations do not reflect the change.
12VAC30-122-150. Requirements for consumer-directed model of service delivery
Comment: Response indicates change was made, but the regulations do not reflect the change.
12VAC30-122-200 Supports Intensity Scale requirements; Virginia Supplemental Questions; levels of supports; support packages
Comment: Response indicates change was made, but the regulations do not reflect the change.
12VAC30-122-400-Group and Individual Supported Employment
Comment: Response indicates Edits were made, but change is not reflected in regulations.
12VAC 122-500 Service facilitation service
Comment: Response indicates Edits were made, but change is not reflected in regulations.
12VAC30-122-90 Waiting List
Comment: Supported living is available in the FIS waiver.
12VAC30-122-120 Provider Requirements
Comment: Should read services and supports.
12VAC30-122-450 Peer support service
The Board recommends allowing this service to be provided virtually. Requiring this service be “provided face-to-face” is unnecessarily limiting. During the past year, we've learned a lot about the benefits of virtual and tele-health options that people with disabilities have experienced. Allowing a virtual option would also mitigate barriers such as transportation and better support statewide availability.
The Board recommends broadening the qualifications for a peer mentor to include competitive integrated employment, or demonstrated leadership abilities and activities. A peer mentor could be a person who chooses to live with their family, is competitively employed and actively involved in the community with a robust social life. Requiring a peer mentor to have "Lived independently in the community for one year" is overly restrictive. The Board recommends modifying as follows: “Peer mentor supports shall be provided by an individual with a developmental disability who has lived independently in the community for at least one year, or has been competively employed for at least one year, or has been in a leadership role in a community or other organization demonstrating self-advocacy and leadership skills and is or has been a recipient of services, including to publicly-funded housing, Medicaid waiver services, work incentives, and supported employment.”
On behalf of SpringHealth Behavioral Health and Integrated Care, I write to recommend allowing associate level clinicians to provider services under 12VAC30-122-550 Therapeutic Consultation.
At SpringHealth we specialize in providing professional behavioral and intervention services for youth and adults diagnosed with Intellectual and Developmental Disabilities (IDD), Autism Spectrum Disorder (ASD), and mental illness. One of our greatest challenges to ensuring those that require services and supports receive them is recruiting licensed clinicians to provide services to adults with IDD, even more so in rural parts of the state. One way to address our workforce challenge and to ensure access for clients in rural areas of Virginia would be to allow associate level clinicians to provider services under Therapeutic Consultation.
Allowing associate level clinicians such as LMHP-RP, LMHP-S, LMHP-R, as well those seeking their BCBA / BCaBA, to provide services under Therapeutic Consultation would also be consistent with Community Mental Health Services under the Medicaid State Plan such as behavior therapy, mental health skill building, and intensive in-home supports, to name a few. This would assist with addressing workforce challenges and shortages and afford level clinicians the opportunity to gain experience working with adults.
Additionally, I would concur with the other comments submitted regarding billing in 15-minute units for Therapeutic Consultation, as this change would standardize billing for providers who offer and bill for multiple services.
I appreciate your consideration of my comments.
Sincerely,
Michelle L. Willingham MS MHA BCBA LBA - V
State Director Virginia
For reference, below are the associated administrative codes:
18VAC115-60-10
18VAC115-20-10
18VAC125-20-10
18VAC140-20-10
From Definitions:
"Qualified developmental disabilities professional" or "QDDP" means a professional who (i) possesses at least one year of documented experience working directly with individuals who have developmental disabilities; (ii) is one of the following: a doctor of medicine or osteopathy, a registered nurse, a provider holding at least a bachelor's degree in a human service field including sociology, social work, special education, rehabilitation engineering, counseling, or psychology; and (iii) possesses the required Virginia or national license, registration, or certification in accordance with his profession, if applicable.
Comment: Consider an option for experience in lieu of bachelor’s degree as with QIDP (5 years experience in lieu of degree). If QIDP is included in this definition - if the roles have been combined we need to ensure that the QIDP allowance for experience is included - particularly for those who have been doing the work. The ability to have experience in lieu of a degree has been a huge motivator for people who have not completed a 4 year degree to make ID services a career.
It is also not clear in the Regs if the supervisor of the staff providing services needs to be a QIDP (QDDP). Again, if the degree is required and the supervisor must be a Q, providers are going to lose some of their best, most loyal leaders.
[ d. e. ] Providers shall prepare and maintain unique person-centered [ progress note ] written documentation [ in the form of progress notes or supports checklist as defined by the service. These shall be ] in each individual's [ medical ] record about the individual's responses supports [ and specific circumstances that prevented provision of the scheduled service, should that occur ] . Such documentation shall be provided to DMAS or its designee upon request. Such documentation shall be written [ , signed, and dated ] on the day the described supports were provided. Documentation that occurs after the date services were provided shall be dated with the date the documentation was completed and also include the date the services were provided within the body of the note. In instances when the individual does not communicate through words, the provider shall note his observations about the individual's condition and observable responses, if any, at the time of service delivery.
Comment: Add “Or” to options of when documentation shall be written. The statements are conflicting and could be interpreted as a citation if note is not completed on day supports were provided.
[ e. f. ] [ Examples of unacceptable Unacceptable ] person-centered progress [ note written documentation notes ] include:
(1) Standardized or formulaic notes;
(2) Notes copied from previous service dates and simply redated;
(3) Notes that are not signed and dated by staff who deliver the service, with the date services were rendered; and
Comment: THERAP allows for another person to enter note for staff member when given verbal input from the staff member, if the need arises. Note includes who provided the service and how service was communicated. Additionally, it is important to include electronic signature as acceptable for providers using EHR.
(4) Person-centered progress [ note written documentation notes ] that [ does do ] not document the individual's unique opinions or observed responses to supports.
Comment: Individual’s unique options? Confusing. Does this mean opinion about their supports or opinions in general?
[?13.?15. ] Perform criminal history record checks for barrier crimes in accordance with applicable licensure?requirements at §§ 37.2-416, 37.2-506, and [?37.2-600?37.2-607 ] of the Code of Virginia, as applicable. If the individual enrolled in the waiver is a minor child, also perform a search of the VDSS Child Protective Services Central Registry. The provider shall not be compensated for services provided to the individual enrolled in the waiver effective on the date and afterwards that any of these records checks verifies that [?the provider has been convicted of barrier crime, as is applicable to the provider's license, or if the provider has a finding in the VDSS Child Protective Services Central Registry (if applicable).?the staff person providing services was ineligible to do so pursuant to the applicable statute.
Comment: We do CPS checks for people providing adult services, is this necessary? APS checks make MUCH MORE SENSE for adult services.
[ 19. Providers shall document and maintain written semi-annual supervision notes for each DSP?and supervisor of DSPs that are signed and dated by the supervisor. Additionally,
Comment: Is this requirement only for DD Waiver? ID Waiver has not had this requirement.
2. Providers shall ensure that DSPs and DSP supervisors pass or have passed, with a minimum score of 80%, a DMAS-approved objective, standardized test of knowledge, skills, and abilities demonstrating knowledge of the topics referenced in subdivision 1 of this subsection prior to providing direct, reimbursable services. Other qualified staff who have passed the knowledge-based test shall work alongside any DSP or supervisor who has not yet passed the test.’
Comment: With ID waiver employees have not been allowed to work until they have completed DSPO, passed the test, and have DSPO Assurance. Is this correct in stating people (including supervisors) can work DD Waiver without these requirements if they are working with someone who has met the criteria.
3. The director of the provider organization or the director's designee shall complete the competencies checklist (DMAS Form P241a) for each DSP supervisor within 180 days from date of hire with annual updates thereafter,
Comment – For Supervisors is this 180 days after hire or 180 days after promotion to supervisor?
Upon discovery of a staff person's inability to demonstrate proficiency, the provider has seven calendar days to begin remediation of the identified skills and document the issue and the actions taken by the agency to confirm proficiency.? This initial seven day process is considered a first episode of one or more identified deficiencies
If proficiency is not reconfirmed within seven days following discovery of a second episode, occurring within three months of the staff person's inability to demonstrate proficiency, the skills being remediated shall only be performed under direct supervision, observation and guidance of qualified staff who document the provision of these supports in the person's record.
Comments: This is confusing. I am reading first episode – 7 days to remediate (what if that does not happen or more time is needed?)
Second episode within 3 months is also confusing. 3 months from first episode or quarterly after Competency checklist completed?
Comment: There is no guidance for appealing the SIS score.
Comment – Community Engagement would also benefit from customized rates for people who need 1:1 staffing.
B. Criteria and allowable activities.
[?2c. Providing routine supports and safety supports with transportation to and from community locations and resources.?]
Comment: Routine and Safety Supports for other needs are also necessary and provide with Community Engagement. They should not be limited to transportation.
C. Service units and limitations
6. This service may include planning community activities with the individuals present in a group of no more than three individuals, although this shall be limited to no more than 10% of the total number of authorized hours per month.
Comment: Clarify that planning may be done at a site where there are more than 3 people, but the planning activity must be limited to 3 people.
D. Provider requirements.
2. For??[?agency directed?]?respite service, the provider shall (i) be licensed by DBHDS as a??[?supportive in-home residential service provider,?]??center-based respite service provider,??[?supportive?] ?in-home respite service provider, out-of-home respite service provider or residential respite service provider; (ii) a VDSS-certified foster care home for children or a VDSS-certified adult foster care home for individuals who do not reside in that foster home; (iii) meet the Virginia Department of Health (VDH) licensing requirements; or (iv) have accreditation from a CMS-recognized organization to be a personal care or respite care provider.
Comment: Return option for providers of other residential services to provide respite services. This service is vastly under supported by providers because of low reimbursement rates. By allowing residential providers to provide respite services when staffing or availability allows, this much needed support would be able to be provided to more people throughout the state.
E. Service documentation and requirements.
[?(1) For behavioral therapeutic consultation, the quarterly review shall include graphed data and a summary of this data.
Comment: For a variety of reasons, is often difficult to get documented data from families and service providers to complete quarterly data graphs. Often feedback on effectiveness of plans is provider verbally during sessions. The graphing of data requirement will cause consultant to have to discontinue services for families who are not able to comply with request for documentation from the consultant.
E. Service Documentation and Requirements
1e. A written review supported by documentation in the individual's record, which is?]??submitted to the support coordinator at least quarterly with the plan for supports modified??[?as appropriate?]?. For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented.
Comment: Does not indicate 10 day grace period to have quarterly review submitted to CSB. This is important to ensure time to complete review.
2. Supervision of DSPs shall be provided consistent with those requirements in 12VAC 30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed, signed by the staff person designated to perform the supervision and oversight shall include, at a minimum, the following: (i) Date of contact or observation; (ii) Person contacted or observed; (iii) A summary about the direct support professional's performance and service delivery; and (iv) Any action planned or taken to correct problems identified during supervision and oversight.?]
Comment – Specify that it can be provided in both 1:1 and group settings.
16 Hours of work & 8 Hours of equal work Should NOT pay the SAME
Regulatory reliance on “a day” as the sole reimbursement unit in group home and sponsored placement residential settings establishes this standard and will be significantly harmful to the fundamental principle of equity, individuals served in those settings and small businesses.
Clearly, from a residential provider perspective “a day” of support and services for an individual who chooses to be in a day/work support program and an individual who chooses not to is not equal; as the need for staffing, travel and support provision is significantly different.
Recommendation – the unit of service for residential programs should be bifurcated into 2 units of service each a per diem but with one representing individuals who choose to participate in a work/day support program outside the home and the other representing individuals who choose not to participate in a work/day program outside the home. Individuals who choose not to participate in a program outside the home should receive a higher reimbursement rate that would bring their reimbursement rate in line with the total daily funding of the other individuals who demonstrate the exact same level of need but do participate in outside work/day programs. This approach would retain all of the benefits claimed for the per diem by Burns and Associates while mitigating the harmful impacts. While logistics of working out an exact amount may be difficult due to the variables involved, the State seems to trust Burns and Associates and they are clearly capable given their past work of calculating the averages and variables and arriving at some defensible figure which even if it were not a direct one for one equalization in every individual case would at least mitigate the gross inequities, violation of individual rights and disadvantaging very small businesses that are occurring right now under this current structure.
The QDDP definition does not address the inadequacy of prior definitions and the requirement in 122-390-D5 only includes by regulatory reference the language “Experience may be substituted for the educational requirement.” This final sentence adds an entire class of individuals to the regulations without providing any clarity whatsoever as to their title, roles, rights and privileges. The guidance document for determining functional equivalency provided some standards but was wholly inadequate by itself for the effective identification, verification and use of this class of individuals – functional equivalents. Overreliance, on this single sentence in the regulations has had a negative impact on utilization of this class of individuals.
1) Devalues an entire class of individuals who have demonstrated exemplary professional performance in serving this role. The current regulation permits the existence of functionally equivalent individuals without any direct recognition (title) or inclusion in the regulatory rights/privileges implied for QDDP’s (holding a license, independently operating a home, training/supervision at upper levels etc.). Individuals in this class, who have clearly met the standard and are performing the function well, are reminded daily when they sign off on paperwork and are unable to know what letters to include after their name to meet the requirement/current vogue for establishing their bona fides on each document. These individuals also find themselves in a regulatory limbo as to what duties they can legitimately perform, as the areas required in the guidance document for establishing functional equivalency appear far broader than the regulatory inclusion (or maybe not, really no way to know). This regulatory limbo is destructive to the morale of individuals who fulfill this function, excessively limits their career advancement opportunities and represents a basic unfairness to the individual who is dedicated a lifetime of work to serving individuals in the population.
2) Disincentivizes the development and utilization of functional equivalents. The current regulation permits the existence of functional equivalent individuals but provides no verification process that would formalize the acceptability of and Individual in that role. Licensing agents will not review the material that establishes equivalency and/or provide written verification that an individual has been determined to meet the standard and neither they nor the department can point you to anyone who will verify that an individual meets the standard. As a result, the Individual and the provider can never be sure if the individuals work product will actually be acceptable to the state, since there are no objective standards nor verification process, any one individual can retroactively be declared unqualified by the state and all of the work/billing they’ve been responsible for disallowed. This regulatory limbo provides a clear barrier to providers investing in the development of functional equivalents. Additionally, this factor coupled with the regulatory limbo for acceptable roles for the functional equivalent incentivizes underutilization of individuals who have developed the knowledge, skills and abilities on their own through decades of experience, limiting the utility of a potentially significant staff resource.
Both individually and collectively these factors significantly hinder the interest in and development of this potentially valuable staff resource and makes the use of functional equivalents much less prevalent in the current service environment.
Reduced utilization of functional equivalents has negative impacts on the employee class, service quality and business operations that fall disproportionately on small businesses.
1) Individuals in the functional equivalency class of employees are treated unfairly. Remember here that we are talking about individuals who through decades of service, training and experience have empirically verified their ability to demonstrate and implement all of the knowledge, skills and abilities required of a QDDP in the provision of their services. However, the system devalues their contribution, creates barriers to professional growth and prohibits them from obtaining the recognition they duly deserve; seemingly dismissing all the hard work they endured to achieve the status and making it an apparent dead-end.
2) Exacerbates the staffing crisis reducing overall service quality. Service quality is impacted in 2 ways 1st – the quality of the overall labor pool is reduced; by dis-incentivizing the use of functional equivalents these individuals are excluded from inclusion in the available supervisory labor pool up front and over the long-term quality employees will leave our services in search of employment that recognizes and rewards their empirical knowledge, skills and abilities (they have lots of options for this). Underutilization of functional equivalents also inflates the wages that have to be dedicated to supervisory staff, as a result of college graduates seeking/feeling entitled to a more significant wage, which directly draws from the overall allocation to wages in the organizational budget and results in lower wages for all DSPs making the direct service positions less attractive to quality individuals. 2nd – overreliance on college graduates reduces service quality –individuals with college degrees who we can hire at the currently low pay rates are seldom if ever superior to the individual with decades of experience and given the wages that we can pay these positions are frequently filled by new graduates or existing graduates who exhibit frequent job hopping, both of which introduce significant turnover in these vital roles undermining the familiarity, stability and continuity of services for individuals served. The use of new graduates is particularly problematic when they are put in charge of DSPs with years of experience, generating resentment among seasoned DSPs who believe that you can’t lead the charge unless you’ve been in the trenches; resulting in decreased morale, supervisory dismissiveness and tensions, all of which impact negatively on service quality. Even more problematic is when the season DSP has to perform roles/functions for the individual with the new or existing college degree, because they simply lack the understanding that can only be gained from years of experience with the population and in providing the services and all of these concerns become significantly exacerbated; decreasing service quality.
3) Business operations, particularly that of small businesses are significantly hampered by a labor shortage/crisis. At the simplest level, forcing reliance on college graduates significantly increases the labor cost for that position, which is a cost that will fall disproportionately on small businesses because they lack the economies of scale, double dipping and multiple career paths that are enjoyed by large bureaucratic businesses. Additionally, the inability to identify and hire qualified college graduates particularly in rural areas has become a significant constraint on our ability to maintain much less expand service provision in the Commonwealth. Reduction in the regulatory disincentives to the development of functional equivalent individuals to fill these vital roles would significantly increase the availability of qualified supervisory personnel who could help fill a significant labor shortage in our field. The refusal of the state to include cost-of-living adjustments and/or regularly scheduled rate refurbishments in the regulations, ensure that the labor crisis in our services will only get worse as inflation and more competitive wages elsewhere draw individuals away from our agencies and the state disincentivizing the development of this potential labor pool makes the crisis more acute; ignoring a potentially significant source of relief.
Recommendation: recognize these individuals formally in the regulation by providing them a title (suggest QDDP functional equivalent), provide a regulatory mechanism which permits verification of their status by DBHDS and recognize regulatory rights for the individual who has achieved that status (i.e. qualifies to hold a license, preform all QDDP functions explicit or implicit for that service and establishes equivalency by regulation).
550.B.2.i - Telehealth and phone options for visits to be permanent.
COMMENT: YAY!! Thank you for this! Telehealth has allowed us to be able to connect with those we are supporting much more frequently and effectively! Love this change.
550.C.5.a,b,and c - Initial SARs will be approved for only 180 days after which point a new SAR will need to be submitted with accompanying documentation including baseline Data. Annual renewals will need to have an annual summary of quarterly data.
COMMENT: Though we understand that the purpose is to assure that plans are meeting the expectation of content, resubmission of a plan for support at 180 will cause delays in continuation of services. In multiple areas of Virginia, we are unable to receive approval for a Plan for Support for a plan renewal in less than 60 days. If it is pended, it will be delayed longer. In addition, initial PFSs will often take 60 to 90 days for authorization. In these cases, we cannot start services until they are approved which is 3 months into the requested plan time and we will have only 3 months of data or information to submit. Followed by further delays in Plan renewal authorization at the 180 day end-date.
We request the removal of the 180 day resubmission requirement and request that the accompanying documentation be required for annual renewal.
550.E.e.(1)and(2) - quarterlies must include graphs and charts
COMMENT: We request that this be modified to read that quarterlies must include summary of progress which may include charts and graphs.
PBSFs rely on team participation for data collection. Surveys within the PBSF community rate data collection as the #1 barrier to plan completion and site that data is often not completed at all or is completed incorrectly. PBSFs often have to resort to record reviews of alternative documentation that the residential provider uses internally, direct observation during visits/telehealth, and anecdotal reports to measure progress and response to interventions. Broadening the scope of this requirement to include a summary of progress will allow for presentation of data as it is available and will afford the PBSF opportunity to document on the quarterly the barriers with obtaining proper data so the team can measure progress with team participation. In addition, it will avoid delay of services to the individual due to pending of authorization by PA when the charts and graphs do not look a particular way.
Peaceable Life Therapeutic Services, Inc. would like to advocate that LPCs and LCSWs who are endorsed to provide Positive Behavioral Supports are able to bill at the highest rate along with “Therapist and BCBAs” as follows:
97139 Therapeutic Consultation, Therapists/Behavior Analysts/Rehab. Engineers
LPCs and LCSWs who provide Therapeutic Consultation for behavior supports are restricted to billing under 97530 as "other professionals" because we are not considered as qualified to provide Therapeutic Behavioral Consultation as a BA.
Licensed Professional Counselors are masters level licensed professionals, completing 4000 supervised clinical hours with 200 direct supervision hours under an LPC. Likewise, LCSWs are masters level licensed professionals, completing 3000 supervised clinical hours with 100 direct supervision hours under an LCSW. In addition to clinical experience, LPC or LCSW with endorsement as a PBSF holds specialized training in evidenced based behavioral support.
Our state struggles to provide quality mental health support to individuals with Developmental Disabilities that also have comorbid conditions related to mental health. In addition to being able to provide interventions for behavioral needs and address behavioral emergencies, PBSFs who are LPCs and LCSWs are uniquely able to integrate resources and strategies related to diagnosed mental health disorders which are contributing to the behavioral needs of the individual as well as evidence based behavioral strategies for behavioral support.
LPCs and LCSWs holding endorsement as a PBSF offer a specialized level of professional qualification to meet highly complex behavioral and mental health comorbid needs and should be able to bill accordingly.
Mcos reduce much needed attendant supports under the false flag not medically neccessary ,the ycollect on diagnosis and complexity and than cut services, My 8 year old boy with mestastic ewings sarcoma in leg and lungs whom had limb salvage surgery, chemo, radiation and still in a cast from his hip to his toes due to complications .Has a gtube continous feedings and medi port in chest , lots of meds non wieght bearing , Incontinent of B?B ,wheelchair bound due to complications is developmentally delayed Global , ID and autism had attendant care hours reduced in the middle of covid,19 Skilled care nursing via epdst could not be found and it was also reduced, Anthem healthkeepers is at it again, Take mcos out of equation and let medicaid dmas decide needs and hours , Enough is enough i pay tax I vote and im done with lip service.
Regarding quarterlies must include data collection - graphs and charts data - in this reference to data - Person Centered Thinking tools also include data as well. Also direct instructional strategies collect baseline/intervention data and could also include progress through prompt levels or other measures for replacement skills. Permanent products are another source of data that can illustrate the progress of objectives that could be related to bx challenges being supported by positive behavior support facilitation.
Staff Requirements:
DD Support Coordination:
Target Group Definition:
VIDES requirement
12VAC30-122-390 - Group home – 6 bed max on group homes.
COMMENT: Family Sharing, Inc. recognizes that residential settings of 6 or fewer beds are the preference for community based services, however, we support comments posted by VNPP which acknowledges "Providers have experienced years of rate stagnation while trying to accommodate the rising costs – the only remedy has been to increase the number of operating beds in the home to gain some economy of scale – the only alternative is to close the home and remove an option for community living. Since 1990, the Code of Virginia at §15.2-2291 has supported Group Homes of 8 beds of fewer by classifying them as “single family residences.” To impose a regulatory limit that is more restrictive is both short-sighted and unnecessary.”
12VAC30-122-200 Support Intensity Scale
200.2.a. 4 years between SIS assessments for ages 22 and over.
COMMENT: Family Sharing, Inc. feels that this distance of time between assessments is detrimental to assuring proper care of the person receiving supports. Currently, requests for re-evaluation are limited and difficult to obtain approval, even when there have been changes to medical or behavioral needs.
Family Sharing requests that the time frame remain 3 years. Should the 4 year span remain, Family Sharing requests that reassessments due to changes be made easier and allowances be made for appeal of results when the team does not feel the level reflects need.
200.B.2. Notations of exceptional medical/behavioral needs will be investigated and may or may not lead to obtaining the exceptional level of services.
COMMENT: Family Sharing expresses concern about the lack of transparency in the scoring of SIS assessments and how the levels are determined. In all other assessments and evaluations, scores are shared with the person being assessed along with a determination summary. Since adopting SIS scoring for rate setting, scoring and interpretation has changed multiple times without transparency.
Family Sharing requests the following:
- scoring and determination criteria be posted,
- justification of any reduction in level or tier be sent to the individual,
- and an avenue for appeal be provided to the individual who wishes to appeal the determination, as is the right of all service recipients related to their diagnosis and treatment assessing and planning.
370.7. Environmental Modification
COMMENT: Environmental Modification Services be allowed for sponsored residential services and group homes in cases in which a person has been living in the home for a lengthy period of time without the need for such modifications and has had a significant change in medical status or mobility/accessibility. It would be a hardship for the individual to be moved to another home that has the needed access, leaving their in place support structure. For many people who have lived in a location for years, they view that as their home, and rightly so. They should not be forced to move because the state refuses to support the person in their home.
390.D.1.e. For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented.
COMMENT: Family Sharing requests clarification -how must “review” of documentation be documented. What supporting documentation must be reviewed?
460.C.3. Personal Assistance clarification – Individuals may receive a combination of personal assistance service, respite service, [ companion, ] and in-home support service as documented in their ISPs but shall not simultaneously receive in-home supports service, personal assistance service, or respite service.
COMMENT: Family Sharing would like clarification – as it is written, it seems that PA can be provided simultaneously with companion
530.C.1. Residential service limit to 344 days per ISP
COMMENT: Family Sharing requests a re-evaluation of the number of allowable days of billing per year, as 21 days is an excessive number of non-service days for the great majority of people in sponsored residential services who do not have family members to visit or have other avenues of support for this amount of time. Care providers must continue to provide 24-hour services during this time as well as pay for additional DSPs.
Therapeutic Consultation 12VAC30-122-550
550.B.2.i - Telehealth and phone options for visits to be permanent.
COMMENT: Thank you for this! Telehealth has allowed us to be able to connect with those we are supporting much more frequently and effectively! Love this change.
550.C.5.a,b,and c - Initial SARs will be approved for only 180 days after which point a new SAR will need to be submitted with accompanying documentation including baseline Data. Annual renewals will need to have an annual summary of quarterly data.
COMMENT: Though we understand that the purpose is to assure that plans are meeting the expectation of content, resubmission of a plan for support at 180 will cause delays in continuation of services. In multiple areas of Virginia, we are unable to receive approval for a Plan for Support for a plan renewal in less than 60 days. If it is pended, it will be delayed longer. In addition, initial PFSs will often take 60 to 90 days for authorization. In these cases, we cannot start services until they are approved which is 3 months into the requested plan time and we will have only 3 months of data or information to submit. Followed by further delays in Plan renewal authorization at the 180 day end-date.
We request the removal of the 180 day resubmission requirement and request that the accompanying documentation be required for annual renewal.
550.E.e.(1)and(2) - quarterlies must include graphs and charts
COMMENT: We request that this be modified to read that quarterlies must include summary of progress which may include charts and graphs.
PBSFs rely on team participation for data collection. Surveys within the PBSF community rate data collection as the #1 barrier to plan completion and site that data is often not completed at all or is completed incorrectly. PBSFs often have to resort to record reviews of alternative documentation that the residential provider uses internally, direct observation during visits/telehealth, and anecdotal reports to measure progress and response to interventions. Broadening the scope of this requirement to include a summary of progress will allow for presentation of data as it is available and will afford the PBSF opportunity to document on the quarterly the barriers with obtaining proper data so the team can measure progress with team participation. In addition, it will avoid delay of services to the individual due to pending of authorization by PA when the charts and graphs do not look a particular way.
In addition, Family Sharing would like to advocate that LPCs and LCSWs who are endorsed to provide Positive Behavioral Supports are able to bill at the highest rate along with “Therapist and BCBAs” as follows:
97139 Therapeutic Consultation, Therapists/Behavior Analysts/Rehab. Engineers
LPCs and LCSWs who provide Therapeutic Consultation for behavior supports are restricted to billing under 97530 as "other professionals" because we are not considered as qualified to provide Therapeutic Behavioral Consultation as a BA.
Licensed Professional Counselors are masters level licensed professionals, completing 4000 supervised clinical hours with 200 direct supervision hours under an LPC. Likewise, LCSWs are masters level licensed professionals, completing 3000 supervised clinical hours with 100 direct supervision hours under an LCSW. In addition to clinical experience, LPC or LCSW with endorsement as a PBSF holds specialized training in evidenced based behavioral support.
Our state struggles to provide quality mental health support to individuals with Developmental Disabilities that also have co-morbid conditions related to mental health. In addition to being able to provide interventions for behavioral needs and address behavioral emergencies, PBSFs who are LPCs and LCSWs are uniquely able to integrate resources and strategies related to diagnosed mental health disorders which are contributing to the behavioral needs of the individual as well as evidence based behavioral strategies for behavioral support.
LPCs and LCSWs holding endorsement as a PBSF offer a specialized level of professional qualification to meet highly complex behavioral and mental health co-morbid needs and should be able to bill accordingly.
12VAC30-122-200 Support Intensity Scale
200.2.a. 4 years between SIS assessments for ages 22 and over.
COMMENT: My agency feels, and I agree as a direct support professional, that this distance of time between assessments is detrimental to assuring proper care of the Person who needs the supports. Currently, requests for re-evaluation are limited and difficult to obtain approval, even when there have been changes to medical or behavioral needs.
I request that the time frame remain 3 years. Should the 4 year span remain, the process for reassessment due to changes be made easier and allowances be made for appeal of results when the team does not feel the level reflects need.
200.B.2. Notations of exceptional medical/behavioral needs will be investigated and may or may not lead to obtaining the exceptional level of services.
COMMENT: My agency, and I as a direct support professional, express concern about the lack of transparency in the scoring of SIS assessments and how the levels are determined. In all other assessments and evaluations, scores are shared with the person being assessed along with a determination summary. Since adopting SIS scoring for rate setting, scoring and interpretation has changed multiple times without transparency.
We requests the following:
- scoring and determination criteria be posted,
- justification of any reduction in level or tier be sent to the individual,
- and an avenue for appeal be provided to the individual who wishes to appeal the determination, as is the right of all service recipients related to their diagnosis and treatment assessing and planning.370.7. Environmental Modification
COMMENT: Environmental Modification Services be allowed for sponsored residential services and group homes in cases in which a person has been living in the home for a lengthy period of time without the need for such modifications and has had a significant change in medical status or mobility/accessibility. It would be a hardship for the individual to be moved to another home that has the needed access, leaving their in place support structure. For many people who have lived in a location for years, they view that as their home, and rightly so. They should not be forced to move because the state refuses to support the person in their home.
530.C.1. Residential service limit to 344 days per ISP
COMMENT: As a provider, I request a re-evaluation of the number of allowable days of billing per year, as 21 days is an excessive number of non-service days for the great majority of people in sponsored residential services who do not have family members to visit or have other avenues of support for this amount of time. As a care provider, I must continue to provide 24-hour services during this time as well as pay for additional DSPs. There is literally nowhere else I could work that would expect someone to work for 504 hours a year for $0 in pay.There are many people working as QIDPs with or without degrees that have years and a wealth of experience that is needed to enhance the quality of lives of people with disabilites. Cumalative years of experience are invaluable and if these regulations are passed it will greatly limit the industry and those it serves.
The SIS assessments often need updating sooner than the current 3yr requirement, and seeking approval for a re-assessment is challenging and rarely successful. Switching to every 4 yrs will only had more hardships. Many times those we serve have significant health and/or behavioral changes more frequently than that.
Reconsideration is requested for this, as 344 max is rarely reasonable for most we serve.
Providers are providing, often intense, care for all 365 days a year in many cases. Limiting the billable days to 344 is detrimental to the ability to find and retain well qualified and experienced providers.
The Virginia Sponsored Residential Provider Group (VaSRPG) is a collaboration of 30 agencies throughout Virginia who provide Sponsored Residential Services with an active membership of 75 participants. VaSRGP is grateful for the opportunity to respond as a group to recent guidance documents for Direct Support Professional and Direct Support Professional Supervisor competencies and appreciates the consideration of our feedback. For any questions related to this document, you may contact either of the following members:
Meneika Chandler, Family Sharing, Inc., familysharingmlc@gmail.com, 540-414-4561
John Weatherspoon, Wall Residences, JWeatherspoon@wallresidences.com, 540-250-8928
VaSRPG would like to put forth the following comments on guidance documents related to Proposed Changes for Waiver Regulations for DD services
12VAC30-122-390 - Group home – 6 bed max on group homes.
COMMENT: VaSRPG recognizes that residential settings of 6 or fewer beds are the preference for community based services, however, we support comments posted by VNPP which acknowledges ”Providers have experienced years of rate stagnation while trying to accommodate the rising costs – the only remedy has been to increase the number of operating beds in the home to gain some economy of scale – the only alternative is to close the home and remove an option for community living. Since 1990, the Code of Virginia at §15.2-2291 has supported Group Homes of 8 beds of fewer by classifying them as ‘single family residences.’ To impose a regulatory limit that is more restrictive is both short-sighted and unnecessary.”
12VAC30-122-200 Support Intensity Scale
200.2.a. 4 years between SIS assessments for ages 22 and over.
COMMENT: VaSRPG feels that this distance of time between assessments is detrimental to assuring proper care of individual. Currently, requests for re-evaluation are limited and difficult to obtain approval, even when there have been changes to medical or behavioral needs.
VaSRPG requests that the time frame remain 3 years. Should the 4 year span remain, VaSRPG request that requesting reassessment due to changes be made easier and allowances be make for appeal of results when the team does not feel the level reflects need.
200.B.2. Notations of exceptional medical/behavioral needs will be investigated and may or may not lead to obtaining the exceptional level of services.
COMMENT: VaSRPG expresses concern about the lack of transparency in the scoring of SIS assessments and how the levels are determined. In all other assessments and evaluations, scores are shared with the person being assessed along with determination summary. Since adopting SIS scoring for rate setting, scoring and interpretation has changed multiple times without transparency.
VaSRPG requests the following:
- scoring and determination criteria be posted,
- justification of any reduction in level or tier be sent to the individual,
- and an avenue for appeal be provided to the individual who wishes to appeal the determination, as is the right of all service recipients related to their diagnosis and treatment assessing and planning.
370.7. Environmental Modification
COMMENT: VaSRPG requests that Environmental Modification Services be allowed for sponsored residential services and group homes in cases in which a person has been living in the home for a lengthy period of time without the need for such modifications and has had a significant change in medical status or mobility/accessibility and it would be a hardship for the individual to be moved to another home that has the needed accommodations available.
390.D.1.e. For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented.
COMMENT: VaSRPG requests clarification -how must “review” of documentation be documented
460.C.3. Personal Assistance clarification – Individuals may receive a combination of personal assistance service, respite service, [ companion, ] and in-home support service as documented in their ISPs but shall not simultaneously receive in-home supports service, personal assistance service, or respite service.
COMMENT: VaSRPG would like clarification – as it is written, it seems that PA can be provided simultaneously with companion
530.C.1. Residential service limit to 344 days per ISP
COMMENT: VaSRPG requests a re-evaluation of the number of allowable days of billing per year, as 21 days is an excessive number of non-service days for the great majority of people in Residential services who do not have family members who are able to take them home for visits. Care providers must continue to provide services during this time as well as pay for additional DSPs and relief staff, though they are unable to receive reimbursement for those non-billable days. Additionally, assurances that a full year of funds are encapsulated in the 344 days of approved services fails to reflect the additional costs to providers brought on by many of the other regulatory changes such as loss of environmental modifications, risk management and quality improvement requirements, and competency requirements.
550.B.2.i - Therapeutic Consultation - Telehealth and phone options for visits to be permanent.
COMMENT: Thank you for this! Telehealth has allowed us to be able to connect with those we are supporting much more frequently and effectively! Love this change.
550.C.5.a,b,and c - Initial SARs will be approved for only 180 days after which point a new SAR will need to be submitted with accompanying documentation including baseline Data. Annual renewals will need to have an annual summary of quarterly data.
COMMENT: Though we understand that the purpose is to assure that plans are meeting the expectation of content, resubmission of a plan for support at 180 will cause delays in continuation of services. In multiple areas of Virginia, we are unable to receive approval for a Plan for Support on a plan renewal in less than 60 days. If it is pended, it will be delayed longer. In addition, initial PFSs will often take 60 to 90 days for authorization. In these cases, we cannot start services until they are approved which is 3 months into the requested plan time and we will have only 3 months of data or information to submit. Followed by further delays in Plan renewal authorization at the 180 day end-date.
We request the removal of the 180 day resubmission requirement and request that the accompanying documentation be required for annual renewal.
550.E.e.(1)and(2) - quarterlies must include graphs and charts
COMMENT: We request that this be modified to read that quarterlies must include summary of progress which may include charts and graphs.
PBSFs rely on team participation for data collection. Surveys within the PBSF community rate data collection as the #1 barrier to plan completion and cite that data is often not completed at all or is completed incorrectly. PBSFs often have to resort to record reviews of alternative documentation that the residential provider uses internally, direct observation during visits/telehealth, and anecdotal reports to measure progress and response to interventions. Broadening the scope of this requirement to include a summary of progress will allow for presentation of data as it is available and will afford the PBSF opportunity to document on the quarterly the barriers with obtaining proper data so the team can measure progress with team participation. In addition, it will avoid delay of services to the individual due to pending of authorization by PA when the charts and graphs do not look a particular way.
In addition, VaSRPG would like to advocate that LPCs and LCSWs who are endorsed to provide Positive Behavioral Supports are able to bill at the highest rate along with “Therapist and BCBAs” as follows:
97139 Therapeutic Consultation, Therapists/Behavior Analysts/Rehab. Engineers
LPCs and LCSWs who provide Therapeutic Consultation for behavior supports are restricted to billing under 97530 as "other professionals" because we are not considered as qualified to provide Therapeutic Behavioral Consultation as a BA.
Licensed Professional Counselors are Master’s level licensed professionals, completing 4000 supervised clinical hours with 200 direct supervision hours under an LPC. Likewise, LCSWs are Master’s level licensed professionals, completing 3000 supervised clinical hours with 100 direct supervision hours under an LCSW. In addition to clinical experience, LPC or LCSW with endorsement as a PBSF holds specialized training in evidenced based behavioral support.
Our state struggles to provide quality mental health support to individuals with Developmental Disabilities that also have comorbid conditions related to mental health. In addition to being able to provide interventions for behavioral needs and address behavioral emergencies, PBSFs who are LPCs and LCSWs are uniquely able to integrate resources and strategies related to diagnosed mental health disorders which are contributing to the behavioral needs of the individual as well as evidence based behavioral strategies for behavioral support.
LPCs and LCSWs holding endorsement as a PBSF offer a specialized level of professional qualification to meet highly complex behavioral and mental health comorbid needs and should be able to bill accordingly.
It is widely known that the support needs of the individuals served in our waivered programs can change quickly. The current span of three years between SIS assessments is often not adequately meeting the need for timely re-evaluation of support needs, so moving this to four years feels like we are moving in the wrong direction. Requests for re-evaluation in accordance with the approved criteria are difficult to obtain, even when the changes to medical/behavioral supports are significant and long-term. Appeals are currently only allowable to the process itself and are not accepted when the team does not feel that the results of the assessment accurately reflect the needs of the individual.
We would advocate against increasing the time span between SIS assessments to four years. Additionally, the process for requesting re-evaluation as support needs change and the appeal process should revamped to ensure that the individuals served are able to receive proper supports, in accordance with the accurate level and tier.
It is widely known that the support needs of the individuals served in our waivered programs can change quickly. The current span of three years between SIS assessments is often not adequately meeting the need for timely re-evaluation of support needs, so moving this to four years feels like we are moving in the wrong direction. Requests for re-evaluation in accordance with the approved criteria are difficult to obtain, even when the changes to medical/behavioral supports are significant and long-term. Appeals are currently only allowable to the process itself and are not accepted when the team does not feel that the results of the assessment accurately reflect the needs of the individual.
We would advocate against increasing the time span between SIS assessments to four years. Additionally, the process for requesting re-evaluation as support needs change and the appeal process should revamped to ensure that the individuals served are able to receive proper supports, in accordance with the accurate level and tier.
Comments Specific to 12VAC30-122-550 Therapeutic consultation
The unit of service shall be one hour.
Comment: change to 15 minute units for accuracy and quality assurance.
Therapeutic consultation shall not be billed solely for purposes of monitoring the individual.
Comment: Please define “monitoring.” We were recently pended and engaged in an extensive back-and-forth discussion with Lead PA Consultant due to different interpretations of “monitoring.” Behavior Analysis requires extensive data collection throughout the development and implementation of the Behavior Support Plan. Once a BSP is developed, it should be considered fluid, as changes are continually made based on direct data analysis. Data collected after the development of the plan should not be considered monitoring, until the individual has reached discharge criteria.
Travel time [ , and ] written preparation [ , and telephone communication ] shall be considered as in-kind expenses within therapeutic consultation service and shall not be reimbursed as separate items.
Comment: Please define written preparation as an in-kind expense. What documentation does this include and not include?
The need for this service shall be based on the individual's ISP and shall be provided to an individual for whom specialized consultation is clinically necessary. Therapeutic consultation service may be provided in individuals' homes and in appropriate community settings, such as licensed or approved homes or day support programs, as long as they are intended to facilitate implementation of individuals' desired outcomes as identified in their ISP.
Comment: We have encountered situations where individuals require crisis stabilization and/or hospitalization after Therapeutic Consultation services have been authorized. In these situations, it is necessary for us to provide therapeutic consultation services in conjunction with these crisis stabilization services in order to support the individual in successfully transitioning back into residential services. Please include that Therapeutic Consultation may be provided in conjunction with crisis stabilization (either in hospital or crisis stabilization unit).
Initial SARs will be approved for only 180 days after which point a new SAR will need to be submitted with accompanying documentation including baseline Data. Annual renewals will need to have an annual summary of quarterly data.
Re-submission of authorization requests after 180 days can and will cause delays in services.
Telehealth
Comment: Please continue to allow telehealth and phone sessions, as this has allowed us to provide services to many individuals and their teams that would not otherwise have been able to receive services (either due to health concerns or location).
The unit of service shall be one hour.
Comment: change to 15 minute units for accuracy and quality assurance.
Therapeutic consultation shall not be billed solely for purposes of monitoring the individual.
Comment: Please define “monitoring.” We were recently pended and engaged in an extensive back-and-forth discussion with Lead PA Consultant due to different interpretations of “monitoring.” Behavior Analysis requires extensive data collection throughout the development and implementation of the Behavior Support Plan. Once a BSP is developed, it should be considered fluid, as changes are continually made based on direct data analysis. Data collected after the development of the plan should not be considered monitoring, until the individual has reached discharge criteria.
Travel time [ , and ] written preparation [ , and telephone communication ] shall be considered as in-kind expenses within therapeutic consultation service and shall not be reimbursed as separate items.
Comment: Please define written preparation as an in-kind expense. What documentation does this include and not include?
The need for this service shall be based on the individual's ISP and shall be provided to an individual for whom specialized consultation is clinically necessary. Therapeutic consultation service may be provided in individuals' homes and in appropriate community settings, such as licensed or approved homes or day support programs, as long as they are intended to facilitate implementation of individuals' desired outcomes as identified in their ISP.
Comment: We have encountered situations where individuals require crisis stabilization and/or hospitalization after Therapeutic Consultation services have been authorized. In these situations, it is necessary for us to provide therapeutic consultation services in conjunction with these crisis stabilization services in order to support the individual in successfully transitioning back into residential services. Please include that Therapeutic Consultation may be provided in conjunction with crisis stabilization (either in hospital or crisis stabilization unit).
Initial SARs will be approved for only 180 days after which point a new SAR will need to be submitted with accompanying documentation including baseline Data. Annual renewals will need to have an annual summary of quarterly data.
Re-submission of authorization requests after 180 days can and will cause delays in services.
Telehealth
Comment: Please continue to allow telehealth and phone sessions, as this has allowed us to provide services to many individuals and their teams that would not otherwise have been able to receive services (either due to health concerns or location).
Why is information about Tiers and Levels being removed? It is unclear if the supplemental questions will be the determining factor for an individuals tier and level, and if so, what standards are being applied. Additionally, the fall risk would not be a valid indicator of the intensity of supports a person requires, because it does not capture preventative supports for falling; it is only scored if an individual has actually fallen which may have occurred for a number of reasons.
Limiting payment for services rendered to 344 days per year instead of 365 is not an accurate reflection of the service needs of people in sponsored residential and group home services. Most in my agency do not go on regular or extended home visits (if any), and many hospital stays do not last 21 days. The assumption that people in services have somewhere else to go, and are out of services three weeks in a year, needs to be re-evaluated based on current data.
Please add language to allow a Nurse Practitioner, in addition to a physician, to order Skilled Nursing services under Waiver for a person in services. Many people in services rely on rural health clinics or residencies that employ a limited number of physicians and are primarily staffed by nurse practitioners. Most residents with complex medical needs in my agency have nurse practitioners assigned as their primary medical care providers, and the NPs are most familiar and attentive to their situations, diagnoses, and health care requirements. Having to wait for physician signatures on skilled nursing service orders (as requested by PA consultants at times) has created delays in obtaining these documents, as MDs in rural clinics often work part time or contractually. This may create problems obtaining community-based nursing care for vulnerable individuals who need it.
Please assure to remove language in #6 about room and board for sponsored residential services not being a component of the service, which is not consistent with group home standards. Alternately, clarification could be made that room and board is not billed to Medicaid for sponsored residential services.
Section 12 VAC 30 – 122 – 200 requires the use of the SIS and provides some specific requirements for use of the scores generated by that instrument; unfortunately, it does not provide specific regulatory requirements for the implementation of the SIS and overly limits the areas to be considered when applying the results of the instrument.
The amount of skepticism that should be directed towards the Virginia system for implementation of the SIS based on this analysis is significant; as there are clear inconsistencies between the Virginia system and the tested system in the users manual. Interestingly, all have the impact of lowering an individual score:
The Virginia system for implementing the SIS creates significant, distinct and meaningful differences between the scores and level assignments generated by the Virginia system and those that would be generated using the procedures in the tested users manual. These different results as proven above cannot lay claim to the same degree of accuracy, reliability or validity as the SIS which uses the user manual. In fact, when contacted and directly ask about the dominant activity approach an aaidd representative could not identify any study where the dominant activity approach to scoring had been employed much less one where it was proven accurate, reliable and valid and when pressed stated “perhaps some of the international studies”; likewise the representative was unable to identify any information in the public domain or peer-reviewed articles about the dominant activity approach. Regardless of what the international studies show, B. Rammstedt (citation above page 5) indicates these results are not readily transferable to the Virginia population.
Preemptively, because the state provides no opportunity for rejoinder, occasionally state representatives indicated that the instrument is “robust” in response to criticisms; which would be a valid response were it true. However, robustness can be tested comparatively, statistically and empirically but there is absolutely no direct evidence that these verifications for robustness have ever been attempted/completed for the changes implemented by the Virginia system. Additionally, given both the direction and the magnitude of changes from the users manual indicated above, the claim of robustness would fail to even meet the minimal non-statistical requirement for robustness which is provided by T. Plumper and E. Neumayer in their work Robustness Test and Statistical Inference; “most applied scholars even today define robustness through an extreme bounds analysis: a baseline model estimate is robust to plausible alternative model specifications [i.e. Scoring changes] if and only if all estimates have the same direction and are statistically significant.” As the analysis above made painstakingly clear the Virginia system changes the direction in the specifications and any direct statistical comparison between results generated by use of the user manual and the Virginia system would find statistically significant lower scores from the Virginia system; proving that claims of robustness are not applicable to the criticisms in this analysis. Finally, it is important to consider the source aaidd is making millions off of the system by keeping the State customer happy and providing the State the smokescreen of a robustness response without any empirical testing or delineated rationale to support the claim should be greeted with more than a grain of salt.
Recommendations –1st the State could demonstrate felicity to the model they continually use as a justification for this regulation and implement the SIS with strict adherence to the user manual – 2nd the State should recognize the existence of changes from the tested/proven user manual and provide a justification, rationale and empirical evidence for the appropriateness of these changes; making adjustments in level assignments as warranted from the information discovered in this analysis and verification of their use of the instrument – 3rd regulatory protections for individuals subjected to the SIS for determining their level of support needs and hence resources, should be provided directly in the regulation to prohibit any changes in the scoring system that are not verified as appropriate and prevent the implementation of future changes without being subjected to an appropriate system of empirical evaluation and meaningful checks and balances – 4th the prohibition against the individual and respondents having even a blank paper and pencil should be rescinded to promote the preservation of data integrity which is essential as indicated by the Department of Health and Human Services guidelines for Responsible Conduct in Data Management “regardless of the discipline, comprehensive documentation of the collection process before, during and after the activity is essential to preserving data integrity”; without this change an independent check to preserve data integrity will not be possible.
The State has gone to great lengths to sell the SIS and these regulatory changes by dressing them up in the language of scientific certainty and the cloak of reliability and validity---BUT WHAT WE WERE PROMISED IS NOT WHAT WE GOT.
In 12 VAC 30 – 122 – 200 the regulations set forth the standards for assigning levels to Individuals but in this version have removed the point indicators for objectively assigning the lower levels making the entire process completely nontransparent and preventing any realistic/meaningful double check on the States assignment compounding the problems with the secret “verification” process for level 6 or 7 (extraordinary medical/behavioral needs) to an individual; however, as written the regulations create confusion about the initial assignment, do not address changes in actual practices for assignment post transition to the SIS – A and fails to provide the transparency that is essential to a basic system of checks and balances that provides protection for individuals who should be assigned to these higher levels of support need. While use of the word “or” (instead of and) in the level assignment criteria table for level 6 and 7 would appear to indicate there are 2 ways to be assigned that level – 1st having a score on the pertinent questions that is higher than the threshold score and 2nd submitting relevant category information for a review that establishes the basis for an assignment. However, this interpretation of the plain text would be wrong as the State has adopted nontransparent practices, that are being implemented now, that make the score on the pertinent questions irrelevant to the actual assignment and changes assignment levels regardless of the score based on a nontransparent review.
The absence of transparency permitted in assigning level 6 and 7 to individuals by these regulations, creates an unequal process that provides power and rights to the government with no equivalent power or rights for the individual to protect them from the government; resulting in unequal treatment, an unfair reduction of resources and the threat of more significant future harm:
Preemptively, because the State does not provide any opportunity for rejoinder and often sets up “straw man” interpretations of criticisms with simple responses:
Recommendations: 1st – revert to the transparent system with clear score indicators for level assignment and that used the score generated on the supplemental questions to assign individuals to level 6 or 7 whenever that score exceeded the published threshold; this would remove the algorithm, reduce the data double standard and protect the individual from review (except where fraud or deception are suspected) and create balance verses the process that unfairly benefits the government budget concerns at the expense of the individual – if the trained assessors scores have to be trusted unquestionably in all other areas why not in this area that is significantly more easily, accurately and objectively evaluated? 2nd – correct the structural/systematic imbalance created by giving the State the right to appeal/verify a SIS score on the supplemental questions with a corresponding right for individuals to appeal/verify a SIS score – why is it that what’s good for the goose is not for the gander? 3rd – require transparency in the assignment of level 6 and 7, this transparency should be required for evaluation of the algorithm and for the review process with identified criteria, standards and written justifications to promote transparency before and after verification reviews. Transparency for these processes would provide important checks on the government and provide records that can be used to stem abuse; as Supreme Court Justice Sandra Day O’Connor stated; “public records are one portal through which the people observe their government ensuring its accountability, integrity and equity while minimizing sovereign mischief and malfeasance”. While these records cannot be made public, transparent provision of records to the individual, guardians, authorized representatives, providers and support coordinators/case managers whom the individual has listed on their Consent to share confidential information form, could be given to these essential advocates and protectors of the individual who would be able to perform the critical function indicated by Justice O’Connor; why should these individuals be denied the tools necessary to perform their function to protect and serve the individuals involved? 4th – include protections and rights for individuals to assure transparency and provide checks and balances for any future changes in the process for making assignments to level 6 or 7. This will be the only way to correct the abuses that are occurring now and prevent even more egregious abuses from occurring in the future, without these protections in the regulations individuals will never be secure in their ability to assure a proper level assignment and hence their just and equitable share of resources as demonstrated by this quotation from a truly great Virginian Patrick Henry “the liberties of a people never were, nor ever will be, secure when the transactions of their rulers can be concealed from them”. Why not regulatorily require transparency in the level assignment process to secure the individuals rights?
In 12 VAC 30 – 122 – 200, the regulations establish the SIS as the key component for establishing individual support needs and funding levels. The State has placed excessive confidence in the SIS which coupled with a meaningless appeals process places a significant number of individuals receiving waiver services at risk for mis-evaluation of their support needs and hence an unfair reduction in their support resources without any meaningful recourse under the existing system.
As is this regulatory set constitutes the State sticking its head in the sand and pretending that there are no SIS errors and based on this willful blindness foreclosing any meaningful avenue of redress for those individuals who are guaranteed to be mis-evaluated and unfairly denied equitable resources based on the States overreliance on the SIS score – this should not be allowed given the significant numbers of individuals who will be impacted this way and the fact that if even just one person is denied justice it harms them and reflects negatively on all of us.
Concur with other comments on new substantive restrictions on group home size inappropriate, need to cover all days in the year at the existing pay rates, SIS inadequacy and competency requirements—all needs to be fixed.
12VAC-30-122-230---Creates the impression that the plan moving forward will be to have all reviews done remotely in B which establishes the requirement to “forward” rather than make available materials needed for the review. While the COVID period may have made remote reviews necessary, they should not be the sole standard moving forward.
The remote review process has been extremely difficult for small providers where the administrative function is typically preformed by 1 individual, who also has a host of other roles. The addition of 75-100 work hours demanded by these reviews often in very limited time frames is an onerous burden that crowds out other duties and undermines quality services. The onsite reviews consistently accomplished the same function in 6-7 work hours and hence lowered the burden to a manageable level, the were also more through and provided a more in depth review of the overall operation making the better on every front. Continued use of remote review after the pandemic should not be allowed or the regulations should be changed to give special considerations to small businesses in the process as required by VA Law when there is an onerous burden on small companies due to a regulatory change.
12VAC30-50-490
Please provide clarification regarding Section E, subsection 3.
Can a support coordinator have family receiving services at the agency where the SC works, assuming that the support coordinator is not providing support coordination to their own family member or does having a family member served at that agency prevent the agency from hiring that family member as a support coordinator?
12VAC30-122-70
Please provided clarification in Section H. as to whom is responsible for the documentation of annual contact with the individuals on the DD waiver waiting list? Does DBHDS contact to obtain the choice of home and community based services meet this requirement?
12VAC30-122-80
Section A, B, and C
These time lines are not reasonable to meet, considering the number of waivers that are distributed at one time. There is no allowance for the number of staff who are working with caseloads at or above capacity that will now have 30 days to contact individuals to inform them of their waiver slot, meet with them that month and start their plan and begin the search for services. There needs to be allowances for boards who don’t have staff to do this. Perhaps splitting how many slots are provided at one time to the boards, not all in one allotment would assist. The lower rate or reimbursement for DD case management, makes it difficult to hire staff prior to distribution of slots to allow for time for the SC to be trained and ready to provide services –before the slots are distributed.
12VAC30-122-90
Please provided clarification regarding Section C. as to how will criteria for assigning slots be met (notification, meeting etc.) be met if the individual is out of the state for three months and receive a slot?
Please provided clarification regarding Section G, subsection 5 when a slot is vacated in one of the DD Waiver due to the death, the slot shall be assigned to the next individual in that CSB’s chronological Queue. Does this mean that anytime an individual passes away their slot goes to the reserve slot waiting list for that CSB or is it just those that received their current waiver through the reserve slot process?
12VAC30-122-150
Section 2, subsection e
If the EOR is acting as the service facilitator – who monitors to ensure that they meet all the requirements of a CD service facilitator?
Who writes the service plans?
Who inputs the plans and service authorizations into WAMS if the EOR is the service facilitator?
12VAC30-122-160
Section 2
For involuntary disenrollment of consumer directed services – how would the support coordinator have the information about timesheets that would indicate a serious discrepancy? What is considered a serious discrepancy?
Section 3 subsection a
What is the essential training that needs to be provided to the EOR to improve the problem condition?
12VAC30-122-200
Section 2, subsection c and e
Who is responsible for completing “another developmental appropriate standardized living skills assessment approved by DBHDS” for those who did not receive a SIS assessment?
How are these assessments funded?