General Comments
• Benefits Planning, Community Guide, Non-medical Transportation/Employment & Community
Transportation Services, Peer Support Services are not included in the proposed regulations but
are current available waiver services. A Medicaid Memo was published September 4, 2018 for
Community Guide, including Community Housing Guide, Peer Mentor Supports and Benefits
Planning Services. Sufficient time has elapsed to include these services in the final DD Waiver
regulations for consistency in waiver implementation. We recognize that including them at this
stage is a substantive change. However, to continue on without regulatory authority is
unacceptable. All waiver services should be included for the purposes of public review and
comment.
• DMAS and DBHDS should create the option for a single agency to have one Plan for Supports
per individual regardless of the number of services provided to an individual in order to streamline
documentation and reduce the number of quarterly reports required. This was a unanimous
recommendation of the DBHDS’s own Provider Issues Resolution Workgroup (PIRW) in its report
published August 2018.
• Support the allowance of employment services organizations (ESOs) to be providers of Peer
Mentor Supports, Employment & Community Transportation Services and Community Guide
services.
• Support the consistent use of “progress notes” as defined in the DD Waiver regulations versus
• the use of “daily note” references. We support the definition of “progress notes” as defined in
12VAC30-122-20 “Definitions” for consistency. “Progress notes” means individual-specific written
documentation that (i) contains unique differences specific to the individual’s circumstances and
the supports provided, and the individual’s responses to such supports; (ii) is signed and dated by
the person who rendered the supports; and (iii) is written and signed and dated as soon as is
practicable but no longer than one week after the referenced service.”
• Support changing the 10-day requirement to a 15-day requirement for service providers to submit
quarterly reports.
• Semi-Annual Supervisory Notes for DSPs including “individual’s satisfaction with service
provision”. Requirement should be eliminated or changed per comments below:
o Community Coaching (122-310.E.2), Community Engagement (122-320.E.2), Group Day
(122-380.D.5.), Group Residential (122-390.D.5), Crisis Support Services (122-350.E.2)
and Center-Based Crisis Support Services (122-300.E.2) all have additional burdensome
requirements under Service Documentation or Provider requirements that state that there
must be written supervision notes for each DSP, signed by the supervisor and included
semi-annual documentation of individual’s satisfaction by the supervisor. (Center-based
Crisis Supports does not include the semi-annual requirement.) Semi-Annual supervisory
documentation of an individual’s “Satisfaction with service provision” or “observation of
satisfaction” is also required.
? This is duplicative of the initial and annual thereafter required documentation of
proficiency of staff competencies included under 122-180. Not to mention, much
more stringent.
? Why some services and not others?
? Consistency between the services does not exist. Group Day requires
documentation of “observation of satisfaction”.
? The requirement of semi-annual notes in the DSP supervision note regarding
“satisfaction of the individual” or “observation of satisfaction of the individual” is not
consistent with the already required individualized documentation. 
? If any one should be documenting an “individual’s satisfaction with service
provision” or “observation of satisfaction” – it should be the support
coordinator/case manager during their regular visits. Someone other than the
provider should be evaluating whether an individual is satisfied with the service
they are receiving from the provider. It’s like the proverbial “rooster guarding the
hen house”. The support coordinator/case manager is the more appropriate
person and, if required, it should be required for all waiver services and not just
some services.
? The requirement of proscribed supervisory notes on a regular semi-annual basis is
another added administrative burden layered on top of the annual DSP staff
competency requirement which was added after the waiver rates were set. Both
cumbersome documentation requirements are not included in any rate.
• Recommend that DMAS and DBHDS actively work with CMS to develop and seek approval of a
checklist to substitute for “progress notes” (narrative daily notes) - the demands of which detract
from providers’ resources to effectively support individuals.
• Virginia should develop and implement a central provider audit tool to decrease multiple requests
of providers for the same information across reviewers. This tool should bring together the
various monitoring entities and result in collaboration and consistency in interpretation across
agencies and reviewers eliminating redundancy in documentation requests. This includes
reviews by DBHDS subcontractors, human rights, licensing and Medicaid regulations and
interpretations by contractors, specialists, quality management and provider integrity.
• Provide for the opportunity for deemed provider status for providers that hold a national
accreditation (CARF) or specific certification to reduce the frequency of reviews. This would
reduce both state government and provider time and money.
12VAC30-50-490. Support Coordination/case management for individuals with developmental
disabilities, including autism.
• Eliminate the term “autism” in the section header. Autism/Autism Spectrum Disorders (ASD) are
included in the term developmental disability.
• A. Eliminate the limitation of case management to individuals who are six years of age and older
and who are on the waiting list or receiving services. Since we have moved to a DD Waiver
system that does not differentiate based on diagnosis, there should not be an age restriction to
the receipt of case management services. This is a remnant from the old IFDDS waiver where
children under six were all served through the ID waiver. If individuals under the age of six are not
in the target group, then it is unclear how they would gain a slot on the DD Waiver wait list or
receive a DD waiver.
12VAC30-122-20. Definitions.
General:
• Definitions for benefits planning, community guide, non-medical transportation/employment and
community transportation services should be added to section.
• Assistive Technology- add following environment “, actively participate in other waiver services
which are part of their plan.”; delete “in which they live”. The current definition does not account
for all of the new and possible future expansive use of technology in all available waiver services.
Expanding the definition will enable waiver services to adapt to the fast pace of changing
technology in all walks of life.
• Community Coaching – add following participating “or to support an individual when there is an
ongoing barrier to participation . . .” [This is an issue of access to the Community Engagement 
service; individuals with chronic medical, sensory or mobility issues, challenging behavioral
issues or a condition which is progressively more debilitating will be barred from Community
Engagement as 1:1 staff exceeds the parameters of the service.]
• Community engagement – delete “one staff person to” or change the last sentence to
“Community Engagement Services shall be provided in groups no larger than 3 individuals with a
minimum of one staff”. Basically, delete the reference to “staff” in the definition. The goal is to
limit the size of the group.
• Independent Living – Add a definition. The term is used throughout the proposed regulations with
no definition. Proposed 12VAC30-122-90 defines the eligibility criteria for the Priority One waiting
list to include young adults who are no longer eligible for IDEA services and who are transitioning
to “independent living.” The regulations describe the individuals whom the Building Independence
Waiver is designed to support as “individuals who reside in an integrated, independent living
arrangement....” (proposed 12VAC30-122-240). Additionally, the Independent living support
service described in proposed 12VAC30-122-420 is available to adults 18 years of age and older
to provide the skill building and supports “necessary to secure and reside in an independent living
situation.” Nowhere in the regulations, however, is the phrase “independent living” as used in
these sections defined.
• Positive Behavior Supports – use the definition of the American Association for Positive Behavior
Supports and delete the language provided. This will bring the service in line with the national
standard.
• Progress Note – We support this definition as written and object to the variations contained in the
Provider Requirement sections of the several service descriptions. See our “General Comments”
above.
• QDDP – add a reference to all sections in this regulation which permit “QDDP” for the purposes
of developing service plans and/or the supervision of staff to be defined in accordance with
12VAC35-105; while it is not necessary for the purposes of the definition, it will add clarity to the
regulations.
• Face-to-face visit- add following support coordinator “or shared living administrative provider”
[Face-to-face is the term used for the periodic meetings required in that service]
• Independent Living – Add a definition
• Service Authorizations- Strike the word “medically”. DD waiver services are all Medicaid-funded
services. However, not all services authorized or funded under the waiver are medical in nature.
(e.g. supported employment, community engagement, etc). While we understand the Medicaid
standard of “medical necessity” for payment, it implies that services must have a physician’s
order and not be developed by the Person-Centered planning process.
• Supported living residential- delete following a service “taking place in an apartment setting”; add
following operated by a DBHDS-licensed provider. Change to “taking place in an individual’s own
home”. There is no operational reason to limit the choice of the type of living arrangement.
12VAC30-122-40. Waiver services; when not authorized.
• B. Clarify that transition services can be provided to individuals who are inpatients at the listed
facilities when they are preparing for discharge. The subsection states that waiver services shall
not be furnished to individuals who are inpatients of a hospital, nursing facilities, ICF/IID, or
inpatient rehabilitation facility. It goes on to state that waiver services shall not be provided until
the individual has exited the institution and has been enrolled in the waiver. However, some of the
costs covered by transition services would have to be incurred prior to the individual exiting the 
institution, in order for the individual to have an alternative place to live. Such expenses include
security deposits, set-up fees, or deposits for utilities, etc.
12VAC30-122-60. Financial eligibility standards for individuals.
• B.3.a.(1) and B.3.b.(1) Delete following employed “at least 8 hours but”. Individuals who work
fewer than eight hours per week are unnecessarily disadvantaged by the limitation. Many
individuals may work less than 8 hours per week because of medical or other reasons. Without
this disregard, there is no incentive for them to work because their income would go to patient
pay.