Fairfax-Falls Church Community Services Board Comments on Proposed Changes to DMAS Mental Health Services Regulations

Part I

Staff review of the proposed changes generated the following comments for consideration:

12VAC30-30-60-143 – PCP:  Support PCP Notification with appropriate client Authorizations in place.

12VAC30-50-130-5: Too many disciplines are being excluded. Nursing is not included as a human services field and should be noted in the list.  How will staff hired under the current list of disciplines be grandfathered?

12VA30-50-130-5-ISP:  ISP  Providers with EHR’s will need time to reconfigure system capabilities to meet any new requirements. Discharge plans are currently included in a variety of ways including in ongoing assessments.

12VAC30-50-130-5 - Community Mental Health Services:  Community Mental Health Services  The term "certified pre-screener" is a term that, in Virginia, is considered to be exclusive to the CSB/BHA clinicians who provide emergency services and pre-admission screening for involuntary detention. This proposed change would be in conflict with the current Code of Virginia and DBHDS Licensing Regulations and removes the CSB/BHA designation as the sole entity to fill the role of certified prescreener.

12VAC30-50-130-5 - Intensive In-Home: IIH is one of the most intensive community cased mental health services provided to children and adolescents with serious emotional disorders (SED).  SEDs are chronic conditions that persist over time and it is essential that children and adolescents with DED receive targeted case management services independent of IIH to ensure that clinical needs of these children and adolescents are being met effectively, coordinated and addressed.

12VAC30-50-130-5 - LMHP:  LMHP – Substance Abuse practitioners are certified not licensed.  Does this mean that the CSAC will no longer be honored?

12VAC30-50-130-5 - QMHP-C:    How will grandfathering and variances be handled related to staff already hired – this is a critical issue. This change will impact the pool of potential staff and adversely affect recruitment. 

12VAC30-50-130-5 - Work Experience:  Requiring “full time experience” would reduce the pool of potential staff and adversely affect recruitment (i.e.  caregivers, part-time workers). There is also need for guidance on the calculation of “clinical experience”. There needs to be a clear definition of the meaning of “supervised”. Also, what is the expectation of how internships, outside of the hiring entity, would be handled or documented?

12VA30-130-3010 - ICA:   Removes the CSB/BHA designation as the sole entity authorized to perform independent clinical assessments.

12VA30-130-3030A – Intensive In-Home:  IIH -Removes the CSB/BHA designation as the sole entity authorized to perform

12VA30-130-3030B – TDT:  Removes the CSB/BHA designation as the sole entity authorized to perform independent clinical assessments.

12VAC30-50-226 - Crisis Services:  Crisis Intervention and Crisis Stabilization proposed requirements for "Registering" with DMAS should be expected only after the crisis intervention has been accomplished; within a designated timeframe.  Additional information about how the registration information will be transmitted to and used by DMAS, as well as staff training will need to be provided.

12VAC30-50-226 - Day Treatment Services:  Day Treatment Services should allow LMHP-e (licensed eligible) to complete face-to-face assessments with approval/sign-off from a LMHP.

12VAC30-50-226 - Intensive In-Home Services:  Intensive In-Home Services should allow LMHP-e (licensed eligible) to complete face-to-face assessments with approval/sign-off from a LMHP.

12VA30-50-226 – ISP:   Loss of person centered language is very concerning.  This should be added back into this section as should the assurance that the recipient is part of service planning.  In addition, providers with EHR’s will need time to reconfigure to meet any new requirements.

12VA30-50-226 – ISP:  Providers with EHR’s will need time to reconfigure to meet any new requirements.

12VAC30-50-226A - Human Services Field:  Too many disciplines are being excluded. Nursing is not included as a human services field and should be noted in the list. Degrees such as Therapeutic Recreation, Educational Psychology and others that cover requisite knowledge and skills are omitted, without option for special consideration.  Flexibility in terms of exceptions should be built in. How will staff hired under the current list of disciplines be grandfathered?

12VAC30-50-226A - Clinical experience:  Suggest deleting “on a full-time basis” or allow clinical experience to be the “equivalent of” an amount of full-time experience.  Otherwise, the pool of providers is more severely limited than what it is now and recruitment will be affected.  Parents and caregivers, for example, may need to work part-time. As well, there should be a flexible process remaining in the regulations for approval of an alternate degree.

12VAC30-50-226A - Activities of Daily Living:  "Activities of Daily Living" - should be expanded to include shopping, budgeting, meal planning, etc.,

12VAC30-50-226A - Certified Pre-screener:  The term "Certified Pre-screener" - should be consistent with the Code of Virginia.  The proposed change would be in conflict with the current code of Virginia and DBHDS licensing regulations.

12VAC30-50-226A - Certified pre-screener: Suggest the language be amended in each section where it is used to be clear about the entity and the precise function.  Do not use the term “certified pre-screener” unless it is accompanied by the prefix “CSB/BHA”.Wording should be reworked to clarify the Certified Pre-screener role is exclusive to the CSB.BHA.

12VAC30-50-226A – LMHP:  After this year, we understand the Psychiatric Clinical Nurse Specialist will no longer be an obtainable specialty, as Masters’ level nurses are now being educated and will be credentialed (board certified) to provide services to children, and adults as Nurse Practitioners. The language needs to be corrected to reflect both psychiatric clinical nurse specialists and psychiatric nurse practitioners as those who are currently double board certified will be grandfathered.

12VAC30-50-226A – QMHP-A and C: How will grandfathering and variances be handled related to staff already hired – this is a critical issue. This change will impact the pool of potential staff and adversely affect recruitment. 

12VAC30-50-226A – Registration:  When CSB/BHA clinicians are addressing emergency situations, triage and stabilization, it should be clearly stated that the interventions are the priority, with Registration to follow. 

12VAC30-50-226A – Registration:  Registration adds another administrative step, which we believe is already accomplished by filing a claim. Based on this requirement, will Crisis Stabilization and Detox programs still be able to do 24/7?

12VAC30-50-226A – Registration: The details of the "Registration" process once the information is to be forwarded by the CSB/BHA need to be clarified, so CSBs can be able to advise individuals receiving services how the information will be used.

12VAC30-50-226A - Work Experience: Requiring “full time experience” and not considering part-time experience would dangerously reduce the pool of potential staff and would adversely affect recruitment of many qualified people who have gained experience as caregivers or part-time staff. 

12VAC30-50-226A – Clinical Experience: There is also need for guidance on the calculation of “clinical experience”. There needs to be a clear definition of the meaning of “supervised”. Also, what is the expectation of how internships, work outside of the hiring entity, would be handled or documented?

12VAC30-50-226B - Intensive Community Treatment:  Licensure through DBHDS for this service is based upon the national PACT model.  By removing case management as a required component of ICT, Virginia’s regulations conflict with the national PACT fidelity standards.  Individuals at this level of care require case management to assist with diversion from hospitalization and to assist with basic needs.

12VAC30-50-226B - Crisis Intervention:  Amount of service that will be needed and provided can hardly be determined in advance.  Individuals in crisis can rarely provide comprehensive information so triage and stabilization is necessary before registration of any kind.   What will happen if the computers are temporarily down or for some other reason staff cannot reach DMAS? Individuals, in this case, may not always be able to provide Medicaid information for registration. As proposed, this registration would be completed only by a certified pre-screener, requiring that the evaluator would need to be an LMHP, QMHP and a pre-screener.  This would disallow many of the CSB current staff to perform this service, since not all of our pre-screeners are licensed.

12VAC30-50-226B - Crisis Stabilization:  Crisis Stabilization services regulations indicate that services are based on the assessment of a QMHP that are then later reviewed and approved by a LMHP within 72 hours. The LMHP is only reviewing and approving the service rather than performing the face to face assessment. Considering the acuteness and brevity of the service, at 3 days the consumer is often discharged.  In order to provide the level of service that is needed for crisis stabilization services the LMHP needs to be more actively involved in the assessment and treatment planning in the early stages of treatment, which would then provide the information necessary for service authorization and also provide for more delineation of the service from crisis intervention and mental health supports.

12VAC30-50-226B - Day Tx: It is important that existing variances be honored.

12VAC30-5-226B - Psychosocial Rehab:  As in other statements, will existing variances for Psychosocial Rehab be honored?  What about for LPNs?

12VAC30-5-226B - QMHP-A: There is a need to clarify that a QMHP-A can continue to conduct the face to face assessment with the LMHP approval.

12VAC30-5-226B1 - Service-specific provider assessment:  Please clarify and define what this is.  Is this the same as a comprehensive assessment?  Should the assessment include specifically the behavioral and primary health needs in health status?

12VAC30-50-226B5 - Crisis Stabilization: Crisis Stabilization  Must staff now be both LMHP, QMHP-A or QMHP-C and a certified pre-screener?

12VAC30-60-61A - Definition of “at risk”:   This more stringent definition in the proposed changes may easily result in fewer children and adolescents with SED qualifying for Intensive In-Home.  If a service such as the Strategic Family Services and Supports Services Model were available, this definition may not have the potential to deny services to those who need them.  That service is not in place, however, and outpatient, clinic-based services may not meet the need.  Again, flexibility and an exception process are needed. This model is designed by the VACSB, endorsed by Voices for VA’s Children.

12VAC30-60-143 - PCP Notification:  With language that assures recipient’s consent to the notification, fully support coordination with PCP.

Part II

The Fairfax-Falls Church Community Services Board endorses the general comments submitted by the Virginia Association of Community Services Boards as reflecting the concerns of our CSB.  Specifically, those comments are:

• The VACSB and our members understand the need to revise and, at times, tighten regulations to assure that those who need services receive them and that the services are of a quality that will maximize the benefits for recipients.  It is obvious that thought has gone into the proposed changes, but at this time, we would voice our concerns.
• At a time when health care needs are expanding but service providers are not expanding in numbers, many of the proposed changes in staffing seem unnecessarily burdensome and restrictive.  For example, individuals who are qualified and wish to work or must work only part-time should not be excluded.  Many providers have developed ways to allow individuals who want/need part-time work that have proven beneficial to recipients of services, the employees and service provider organizations.  Language could be added to the proposed changes that clinical experience could be the “equivalent of” an amount of full time experience.  It may take a person longer to meet the requirement but would not restrict them completely.
• As well, grandfathering and approved variances should continue to be allowed and remain in effect.  Otherwise, the system loses many experienced and valued employees. If individuals are qualified under the current regulations, they should be grandfathered under these proposed changes, using the verification/documentation of clinical and supervisory experience under the existing regulations.  While our specific comments below address some of the proposed changes, please allow this general comment to serve as a request to retain grandfathering and variances throughout.
• Various sections indicate that any “incomplete, missing or outdated” documentation will result in denied reimbursement. Any section about inadequate documentation should include wording that any failure needs to be significant, not minor and incidental, or that documentation that is not in “substantial compliance with regs” will result in refusal of reimbursement. The purpose of documentation review is to assure that a covered service is delivered to a covered individual in a clinically appropriate way. Documentation should not be used as a vehicle to deny legitimate reimbursement. We request that the language be amended wherever in the proposed regulations this wording is employed.
• There are a number of places in the Proposed Regulations that appear to have changed or deleted the person-centered language that should remain in regulation if Virginia is to move into a truly person-centered health system.  Recipient planning and expressing preferences, goals, treatment options, and the like should be reflected as high values in the regulations.  As well, there are instances in the proposed changes that would appear to allow exchange of information without expressly stating that the recipient’s consent will be necessary.  Such language should be scrubbed and every attempt made to empower the recipients of services to take an active role in their treatment planning and implementation.
• Sections that describe Activities of Daily Living (ADLs) seem to reflect more of a focus for developmental disabilities than for behavioral health conditions.  We suggest that Instrumental Activity of Daily Living (IADLs) be added.    We have proposed appropriate language that would assist individuals with serious mental illness.  Adding IADLs would also address the language.
• There are areas of the proposed regulations that do not, but should, contain enough flexibility to be sure that a recipient who, by way of functioning or diagnosis, needs a more intensive level of service than what is available in the outpatient realm, is able to receive that service through some exception process whereby appropriate documentation would be forwarded to the pre-authorization contractor. 
• The section involving Crisis Intervention and Registration needs additional thought and change.  “Registration” should occur after the individual is triaged and in a safe clinical setting.  “Crisis Intervention, Amount of Service” should be documented after the person is triaged in a safe clinical setting, and initial level of care is determined.  Under both, the provider first meets the person where he/she is “clinically.” Triage occurs to determine a level of risk, level of crisis, harm to self or others and recommended level of care. Once this is determined and the person is safe, then proceed to register and document what is projected to be the needed level of care.
• We request that DMAS separate clearly the role of CSB/BHAs mandated requirements in Code from what is termed Crisis Stabilization and Crisis Intervention.