Thank you for the opportunity to make comment on these proposed regulations. My comment/questions are below:
Overall, it is believed that lumping Crisis Stabilization, Mobile Crisis Response, REACH, and Emergency Services into a single license there is a general lack of clarity and the context in which each service is provided is lost. Each service has a defined purpose across the crisis continuum and in some cases such as pre-admission screening, it creates blurred boundaries of public and private responsibilities outlined in Virginia Code and does not properly take into account the unique training required by Pre-Admission Screeners. We recommend separate and distinct licenses for each of these services to clarify staff training requirements, team compositions, and to maintain fidelity to the services outlined.
Please see the recommendations/clarifications below per section of the draft.
12VAC35-111-10 - Definitions
Behavior Interventions: This definition does not provide clarity to know when this would apply. Due to the nature of an MCR and / or Emergency Services Pre-Screening, it cannot be presumed that assessors will consistently have access to assessment / records for services rendered outside of their own agency.
Community Based Crisis Stabilization: It is recommended that “Community Stabilization” should be used instead of “Community Based Crisis Stabilization” to be more consistent with DMAS language and service definitions. The following definition revision is recommended:
“Community-based crisis stabilization” means services that are short-term and designed to support an individual and their natural support system following contact with an initial crisis response service or as a diversion from a higher level of care. Providers deliver community-based crisis stabilization services in an individual’s natural environment whenever feasible; services provided in a setting that is not the person’s natural environment should be clinically justifiable and with reasons for such documented in the ISP and progress notes. Providers will make referrals and linkages to other community-based services with consent by the individual, which may include linking to specialized services such as those to address needs of individuals with developmental disabilities, children, and / or individuals needing support with substances. Provision of information and / or linkages to resource assistance programs and / or benefits a person may be eligible to receive may be provided if through this linkage a person’s socioeconomic stressors are likely to be reduced and potentially reduce likelihood of future crises. The goal of community based crisis stabilization services is to stabilize the individual within their community and support the individual and/or, as appropriate, the individual’s support system during the periods 1) between an initial mobile crisis response and entry into an established follow-up service at the appropriate level of care 2) as a transitional step-down from a higher level of care if the next level of care service is identified but not immediately available for access or 3) as a diversion from a higher level of care.”
Crisis Education and Prevention Plan (CEPP): It is recommended to adjust the language from “…experiencing a behavioral loss on control” to “behavioral crisis” as this language aligns closer with a person-centered approach.
Initial Assessment: It is unclear what is being clarified with the added language “an assessment is not a service”.
Initial Individualized Service Plan: The timeframe states 24 hours but we need to double-check that this is consistent in all specific services as we were thinking that CSU gives 48 hours to complete the crisis ISP. (see pg. 16)
Is this referring to the “Crisis ISP” that is referenced throughout the rest of the document? Recommend removing “Initial ISP” def and replacing with a clear definition for Crisis ISP.
12VAC35-111-20- Licenses
Pg.9:
The following licenses are recommended:
12VAC35 – 111-30 Service Descriptions
A – Crisis Receiving Centers: It is indicated that a nursing assessment is required. This contradicts the regulation in the Nursing Assessment section that indicates that nursing assessments are not required for Crisis Receiving Centers.
The regulation states that CRCs shall provide safety to children accompanying parents receiving services. It is recommended that this language is adjusted to state that the provider shall have a policy to address custody of children accompany parents but shall not be responsible for the children’s safety on the unit. Additionally, there should be a requirement for addressing children being assessed at the Crisis Receiving Center accompanied by their parents.
B – Community Based Crisis Stabilization: Combining multiple services under one license presents as very confusing in terms of what services are required to providers. Recommend breaking out service by service in the regulations as outlined above in the list of recommended licensed services.
It is suggested that “Emergency Services” and requirements of uniform pre-admission screening be clearly defined under a unique license to reflect the codified responsibilities and training / supervision requirements that are significantly unique to this public / mandated service.
C – Crisis Stabilization Units (RCSU): The regulation states that providers shall provide safety to children accompanying parents receiving services. It is recommended that this language is adjusted to state that the provider shall have a policy to address custody of children accompany parents but shall not be responsible for the children’s safety on the unit. Additionally, there should be a requirement for addressing children being assessed in a CSU to be accompanied by their parents or other legally designated substitute decision-maker (ie., DSS, kinship placement, etc).
D : The proposed regulation indicates that individuals cannot enter into “a REACH service” if they are actively using substances; however this is too broad as substances include nicotine, THC / CBD, etc. which do not / should not preclude someone from accessing REACH services. We DO strongly support the section related to not being able to support someone [at a REACH CTH] who is in active detox.
12VAC35 – 111- 40 Staffing
B: Community Based Crisis Stabilization Staffing for the community based crisis continuum services is complex and even more so in this section due to the bundling of multiple services under a singular license. It is recommended that these services are broken out under separate licenses to ensure accurate staffing requirements are addressed.
B1: Recommend to update to specify that the assessment is a crisis assessment and remove the CEPP language.
B2: This requirement is possibly a requirement of the VCC platform and is inappropriate to include in a licensing regulation.
B3 ii: Providers of mobile crisis response do not “dispatch” calls as this is a function of the regional hub and PRS/988. It is recommended to rephrase the regulation to read: “If a team response is recommended at dispatch…”
B3 ii – 6: It is recommended to change the language from QMHP-E to QMHP-T
C5 - A separate license is recommended for the REACH CTH; the MCO’s accept this definition for billing purposes. We would benefit from having licensing also recognize the REACH CTHs as a setting that provides crisis stabilization services. Recommend ensuring alignment with DOJ requirements.
D - It is recommended to not treat REACH differently than the rest of the crisis continuum when it comes to licensing regulations. The REACH Standards also, are not licensing regulations and therefore licensing regulations should not point readers / programs to this document which is not kept current and does not presently align with these draft regulations. Having separate guidance documents is not beneficial to community or providers. Additionally, REACH provides Community Crisis Stabilization, MCR and Crisis Therapeutic Home services, however Crisis Therapeutic Home regulations do not presently exist. It is further confusing for regulations to reference that some of the CTHs operate under RCSU licensing regulations; The REACH CTHs require their own CLEAR set of expectations to ensure consistency in operations, reduction in barriers to admission and consistency in systemic oversight statewide.
12VAC35 – 111 – 50 Initial Contacts
A -It is recommended that “initial contact” be defined in the definitions section.
This requirement is overly cumbersome administratively for inquiries that are not of a crisis nature. Please add clarifying language regarding intent OR recommend that these added reporting requirements be removed. Additionally, making service linkages or referrals would not be in scope depending on the type of services that is being contacted, unless a service is rendered.
12VAC35 – 111 – 60 Assessment
D: A crisis assessment is not the same thing as a comprehensive assessment due to the nature of the service and availability of records in a crisis.
It is recommended that the current DBHDS approved crisis assessment components align with the regulations as they currently do not match what is written here. The elements listed in the draft regulations are more closely aligned with a CNA than the crisis assessment.
F(10)b: For Crisis Stabilization Units and Community Based Crisis Stabilization, it is recommended that the regulations allow for providers to complete an addendum to the assessment; if a general crisis assessment or pre-screening is completed within the last 72 hours, an addendum should be allowed. Engaging an individual in an assessment process multiple times does not align with a person-centered or trauma-informed approach to care, particularly when a person is presenting as unstable due to crisis needs.
H: Record retention should not be included as it is already covered in the general regulations.
12VAC35 – 111 – 70 Safety plans and Crisis ISP
B: It is recommended that a singular CEPP be required for REACH services; A Safety Plan at the point of crisis assessment with a CEPP developed during the course of community crisis stabilization admissions or CTH admission would align more closely with the rest of the Crisis Continuum.
12VAC35 – 111 – 80 Safety plan and Crisis ISP requirements
D1 & D2: It is recommended to omit the underlined portions. Undue burden is placed on providers of short term, crisis services to make multiple attempts to obtain signatures beyond 48 hours. There is too much focus on documenting the attempts to obtain client signatures than on the clinical treatment they are in need of and receiving. Attempts are made to obtain signatures within the first 48 hours; documenting refusals and attempts during that timeframe should be sufficient as ongoing attempts beyond that period can damage the therapeutic relationship / trust and places focus on the wrong aspect of care.
12VAC35 – 111 – 90 Reassessments and Review of safety plans and Crisis ISPs
A: This section should clearly define what services this regulation applies to. It is recommended that this regulation does not apply to services that are for 72 hours or less.
12VAC35 – 111 – 100 Progress notes or other documentation
A: It is recommended that these regulations be further clarified or completely omitted from draft as it is redundant to section B which includes specifics of what should be included in progress notes.
B: Recommend removal of this item; general regs should suffice for progress note documentation
12VAC35 – 111 – 110 Discharge Planning
A: It appears the wrong code is referenced; the correct code should be 12VAC35-105-693. In general, the entire Discharge Planning section is unclear and contradictory in terms of what services are required to do and at what discharge planning steps.
B: It is unclear why a Crisis Receiving Center would not be required to provide discharge planning instructions and coordinate care with the rest of the service system on behalf of the individual served.
G: It is recommended that we document progress towards Crisis ISP instead of language related to “criteria for discharge” which adds additional burden for crisis services that supersedes what longer term services are providing.
12VAC35 – 111 -120 Written policies and procedures for crisis or emergency response; required elements
C4: It is recommended to remove “face sheet” terminology as the emergency medical information is present in different locations depending on the agency EHR.
12VAC35 – 111 - 130 Nursing assessment
A: This regulation does not align with DMAS regulations which require the nursing assessment at admission for any residential service and the 23-hour program. It was also noted previously that this regulation contradicts the regulation in 12VAC35-111-30. Service Descriptions (A).
C: The first sentence should be revised to “Prior to admission to (specify which service type)…”
D: Recommend removal of the first sentence as it is not needed or clarify as a “medical professional” shall conduct a nursing assessment.
It is recommended to clarify the type of service setting this requirement pertains to as resources vary by organization. It is also recommended to remove all language between “transfer to a more intensive level of care” and the last sentence of the paragraph. Nurses are not responsible for diagnosing underlying conditions.
H: It is recommended to add the qualifier “unless the provider has access to a shared electronic health record.”
12VAC35 – 111 – 140 Health Care Policy
B4: It’s unreasonable to expect CSUs and CTHs providing short term services to schedule “routine ongoing and follow up” medical and dental appointments; recommend revising to reflect need for this support to address “acute” medical and dental needs only.
C: General regs should cover the fall risk requirements; also, all services that admit a person to treatment are required to do a fall risk assessment so this is not inclusive of other services that are required to complete the fall risk assessment.
12 VAC35-111-230 Nutrition
B.1.b: Recommend remove the “provide methods to learn” from this requirement as this is unclear what all is being asked of the programs. Typically dietary needs of patients is specified on medical orders.
B.2.e: What is “periodically?” If this is not anticipated to be monitored / regulated, recommend removing.
12 VAC35-111-240 Beds or Recliners
G: Recommend removal of this item; tracking the number of days between laundering sheets is administratively burdensome. Physical environment / site visits should focus on whether the bedding is “clean” as specified in item A of this section.
12 VAC35-111-250 Bedrooms
B 1 & 2: Recommend language that indicates that for New services to be licensed they must meet these specified dimensions so that existing services that may not meet these specifications can be grandfathered in.
D: Same comment as B1&2 re: existing sites and grandfathering
E: Recommend “reduce risk” instead of “prevent” language since it’s impossible to fully prevent risk of harm to self by others
I: Clarify “provide separate sleeping areas” - does this mean separate wings or separate bedrooms.
J: This appears to be pulled directly from Children’s PRTF / Residential Treatment regs; question whether this is a needed requirement
12 VAC35-111-260 Physical environment
F: These water temps do not align with general physical env regs; recommend NOT attempting to duplicate sections of the general regs in each separate service regulations due to risk of inconsistencies and increased admin burden on not only licensing but the provider system.
M: Remove “prevent harm” language and replace with reduce risk language
O: This section was pulled from Children’s PRTF regs which is NOT the same level of care as Child CSU / CTH.
O.2 –Example It’s HIGHLY unusual for a CSU to have a Bathtub in their facilities
P1: Video cameras exist outside entrance in many cases; recommend revising language to be that the provider obtain written consent at admission instead of “Before admission”
12 VAC35-111-300 Floor plan and building modifications
What constitutes a building renovation especially for buildings where you incur a lot of damage. It’s a burden that every time you paint a wall, etc. that you need to submit this, especially when you require the building to be in good condition
12 VAC35-111-310 Lighting
Not consistent with other sections or chapters; please clarify if other sources are allowed when the electricity is out.