General Comments:

·         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.

12VAC30-122-20 

12VAC30-122-20. Definitions.

·         Assistive Technology – broaden definition beyond “in which they live“, to “actively participate in other waiver services which are part of their plan.” or to help an individual to be more independent in any setting or any environment including hone, work, school or community social activities.”

·         Challenging behavior-in the final sentence, after “may include” add “but not be limited to”.

·         Family-remove Legal Guardian from list and have a separate and distinct definition for legal guardian (including role, responsibilities and limitations)

·         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 in Definitions:

"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.

·         QDDP - The 2016 (emergency) version of these Waiver regulations included the phrase “or a provider who has documented equivalent experience” to allow providers to substitute experience for a college degree, but this phrase is not included in either the new (2018) Licensing regulations or within the definition of QDDP in these Waiver regulations.   We recommend restoring 2016 language to allow for equivalent experience to substitute for education.

·         Service Authorization – The term “medical necessity” can be misinterpreted to mean that a service must be ordered by a physician rather than being developed by the person-centered planning process.  Medical necessity as required by Medicaid is already established in Medicaid regulations and should not be included in references to service authorization.

12VAC30-122-40

12VAC30-122-40 Waiver services: when not authorized

 

B. We recommend that both assignment of Waiver slots and funding to service providers be available for individuals transitioning out of community ICFs and nursing facilities for up to 60 days prior to discharge to facilitate an efficient and effective transition.

12VAC30-122-60 

12VAC30-122-60. Financial eligibility standards for individuals.

The following language is not included; we recommend including this text for accountability and clarity regarding co-payment collection

B. Patient pay methodology.

Suggest adding: “The support coordinator is responsible for determining which Waiver provider will receive the greater Medicaid reimbursement, and will therefore be responsible for collecting the Medicaid co-payment from the individual.  The support coordinator will notify all Waiver providers which provider will collect the monthly co-payment and in what amount.  Notification will be in writing from the support coordinator to the individual and to all Waiver providers.” 

Recommend Spend-down for ALL Long-Term Care Waiver categories.  This language already is written in CCC+ Waiver regulations and should be included in ALL Long-Term Care Waivers.

12VAC30-122-80 

12VAC30-122-80. Waiver approval process; authorizing and accessing services.

C.4. Following initiated within change “30 days” to “90 days,” Taking into account the existing workforce recruitment timeframes, training requirements, etc. services can not realistically be initiated in only 30 days.  If there are other requirements to notify DSS within that timeframe then the 30-day requirement in line 4 will have to remain. Ensure that references to days (days vs. calendar days) are consistent. There are a variety of reasons that can create a delay of service initiation beyond 30 days. The individual should not be penalized by having to undergo another financial eligibility determination because the provider does not initiate services in a timely manner.

12VAC30-122-90

12VAC30-122-90 Waiting List

C.1.a. – Following care for the individual add “a primary care giver who is 70 years of age or greater”. While we recognize that the age criterion was removed during the “redesign,” we feel that the impact has been significant on older families. It also limits the family’s ability to assist their adult children to make life decisions before it is an emergency.

12VAC30-122-120 

12VAC30-122-120. Provider requirements.

A.10.d states “Such documentation shall be written on the date of service delivery”.  We suggest instead that this language be consistent with the definition of Progress Note referenced in Section 20 (definitions):

"Progress notes" means individual-specific written documentation that

(iv)            Contains unique differences specific to the individual's circumstances and the supports provided, and the individual's responses to such supports;

(v)              Is signed and dated by the person who rendered the supports; and

(vi)            Is written and signed and dated as soon as is practicable but no longer than one week after the referenced service.

In addition, we request that DMAS and DBHDS actively work with CMS to develop and seek approval of a checklist to replace the narrative portion of progress notes - the demands of which detract from providers’ resources to effectively support individuals.  We recommend that this checklist includes all required information and is displayed as a checklist.

We recommend that whenever the term “written” is used, it is inclusive of electronic documentation, such as but not limited to dictation, voice to text or audio files.

A.4.- Change “30 calendar days” to “90 calendar days” [See comment above in Section 80]

A.5.- Strike “medically necessary services and supplies” and add “services and supports”

A.6.- Strike “supplies” and add “supports”

A.10.d- Strike “medical” in the first sentence

A.10.f- Add “if applicable” within the parenthetical phrase “including specific timeframe”

A.13- Change 37.2-600 to 37.2-607

A.14- Strike “-s of Licensing and” [Abuse and neglect are reported to the Office of Human Rights not the Office of Licensing]

D- Strike “may” add “shall” in last sentence [If the purpose is to improve or remove poor providers then this should not be an option]

12VAC30-122-180 

12VAC30-122-180. Orientation testing; professional competency requirements; advanced competency requirements. 

A.2. refers to the standardized test as “DMAS approved” while the 2016 version of the regulations refers to the test as “DBHDS” approved.  Please clarify which agency must approve the test, and also describe the process of approval, and finally include a list of approved standardized tests and resources for providers. 

A provider often needs to have all staff certified for advanced competencies, not just those directly assigned to specific individuals with SIS scores at levels 6 or 7.  For instance, if the regularly assigned “advanced trained” staff are absent, other staff must be deployed to serve those individuals. Also, staff may request transfers or accept promotions.  Providers need staff to be “advanced trained” to move between sites and assignments.  Therefore, the impact of compliance cannot be measured only by the number of individuals assessed at level 6 or 7.  A provider may need to have all staff trained in advanced competencies.

In consideration of this logistical reality, we recommend a substitution for the core and advanced competency checklists whenever a staff has completed the State mandated trainings and met the minimum requirements of acquiring these core competencies.  We further recommend that Staff with one year of experience can substitute this experience for the advanced competency checklists associated with levels 6 and 7.

C.1.- The reference should to the “personnel file” not the “provider record”

D.1- The reference should to the “personnel file” not the “provider record”

12VAC30-122-190 

12VAC30-122-190. Individual support plan; plans for supports; reevaluation of service need.

A.8 states a requirement that “individuals and the family/caregiver shall be provided with a copy of the individual’s ISP”. 

We suggest the following clarifying language, “The support coordinator shall provide the individual and the family/caregiver with a copy of the individual’s full Person Centered ISP including all Part Vs.”

We recommend the following additional text here OR in the appropriate section of 12VAC30-50:

“The support coordinator shall conduct capacity screenings as a preliminary assessment of significant change.  When the results of the capacity screening indicate the need for a full capacity assessment, the support coordinator shall coordinate a full capacity evaluation.  If a qualified examiner evaluates the individual

al and indicates that the individual is unable to give informed consent, the support coordinator shall provide the individual and family with a list of local attorneys known to assist in pursuing legal guardianship.  If the individual and family cannot afford the services of an attorney or decline to pursue guardianship, the support coordinator will follow the Code of Virginia, all regulations, and CSB procedures for appointing an authorized representative.  The support coordinator will inform all providers about the appointment of an authorized representative. The support coordinator shall convey to DBHDS and to DMAS the names of all individuals who need public guardianship.” 

12VAC30-122-200 

12VAC30-122-200. Supports Intensity Scale® requirements; Virginia Supplemental Questions; levels of support; supports packages.

A.1 refers to individuals age 16-72 while A.2.a. refers to individuals aged 16 and older.  We suggest the following language, “Individuals who are older than 72 years of age shall be assessed using either the SIS or an alternative instrument [alternative instrument or instruments to be named in the regulations].” 

A.2.a - Change “three” to “four” in order to be consistent with the CL application 

A.4.- The specific scoring protocol should be in a Medicaid Memorandum AND the Medicaid Waiver manual, not in the regulations.

D - Strike entre paragraph based on 2019 General Assembly action AND add a new paragraph D: “Requires that the results of the SIS be provided within 10 days of scoring in an understandable format and that the support coordinator be required to explain the results and implications of the SIS score.”

Add a new E.- “An automatic, independent review by the support coordinator of the SIS administration process and results when an individual’s SIS Score changes despite a lack of change in their health or other circumstances, upon request.”

12VAC30-122-210 

12VAC30-122-210. Payment for covered services (tiers).

C.1. Recommend an increase to the $5,000 annual limit on assistive technology deemed appropriate to the cost and utility of today’s technology. The current limit is years old and has not kept up with changes in technology and/or the emphasis on expanding the use of technology to replace more cost intensive staffing services. If raising the overall limit is not feasible at this time, we recommend adopting a multi-year limit, such as $10,000 over the course of two years, etc. This would allow greater flexibility for individuals to accommodate upfront costs of purchasing new assistive technology without raising the overall multi-year dollar limits. The limit is also included in 12VAC30-122-270 Assistive technology service. ?

12VAC30-122-270

 12VAC30-122-270 Assistive technology service

A. (ii)- STRIKE “with the environment in which they live” and ADD a new (iii) “actively participate in other waiver services that are part of their plan.” Renumber the current item (iii) to item (iv). AT should be available to support any service in a person’s ISP. It should not be limited to the environment in which the individual lives. It should be available to support an individual in any approved service and promote inclusion in all aspects of an individual’s life.

C.2. The language is restrictive in NOT allowing assistive technology to be used for recreation or leisure activities, “The AT service shall not be approved for purposes of convenience of the caregiver or restraint of the individual, recreation or leisure activities, or educational purposes.”  We recommend STRIKING the reference to “recreation or leisure activities”

Assistive Technology can be invaluable in helping a person gain independence and access to community opportunities.  The use of assistive technology is actually an investment that has potential for a high return on investment for the State. Some forms of assistive technology can increase a person’s independence and decrease their need for staffing, thereby saving an ongoing cost from a one-time investment.  

12VAC30-122-380

Group day service

Include the allowable activity of “providing safety supports in a variety of community settings”.  This allowable activity is included in the CL Waiver renewal application.  Further, the CL renewal application includes “personal care types of activities (i.e. assistance with ADLs)” yet this allowable activity is not listed in either these proposed regulations or in the 2016 version of regulations.  These refer to support activities rather than the requirement for skill building; we recommend that this phrase offers more flexibility for providers who are spending significant time in personal care supports other than in skill-building. 

D.5.  Supervision – Licensing regulations do not define a “supervisor” but do define a QDDP. If in fact these regulations are meant to refer to a QDDP, we note that the 2016 version of the Waiver regulations included the phrase “or a provider who has documented equivalent experience” to allow providers to substitute experience for a college degree.  This phrase is not included in either the new (2018) Licensing regulations or within the definition of QDDP in these Waiver regulations.  Providers request consistency and clarity within and between regulations.

12VAC30-122-400

Group and individual supported employment service

This section needs clarity as to which statements apply to either GSE or ISE, or to both.

A.3.a. includes the phrase “reimbursement shall not be limited for the supervisory activities.” The previous regulations used the term “rendered” instead of “limited.”  Is this an intentional change or an error?  We recommend substituting the term “rendered” and striking “limited”.  

B.1. – Add “and enrolled in school” after for individuals younger than 22 years of age. Strike “for ?the individual enrolled in the waiver”. ?

B.4.a. Add “with or without the individual present”

C.3. – Strike “and individual”. Individual SE must be able to be provided in an individual’s home for purposes of self-employment or other individuals who work from home for other employers (telecommuting, etc.) ?

C.4. – Strike “service” after employment. Strike “in combination with other day service or residential service” and substitute reference to Waiver services and strike the parenthetical reference to 24 hours.  Expand text after job development.

Recommended revision:    “For time-limited service authorized periods, individual supported employment may be provided for purposes of job discovery, individualized job development, negotiation with respective employers, and ongoing support necessary to ensure job retention with or without the individual present ”.

C.7. This documented ineligibility requirement is unclear as to who is responsible for obtaining and/or maintaining ineligibility in records.  We recommend that it be the support coordinator’s responsibility.

D.4. – Second paragraph under this Provider Requirements section is duplicative to 400.A.3.b (Service Description) and is not related to Provider Requirements.   STRIKE.

E.1.c. – Sentence needs to be reworked.  “Documentation confirming the individual’s time in service” is for Group Supported Employment (GSE) only. 

“Daily note” is only applicable to GSE as well. Strike “daily note” and insert “progress note” to be consistent with other sections and definition of “progress note” in Section 122-20. 

E.1.f. - Sentence needs to be reworked.  Should read “Documentation that indicates the date, type of service rendered, and the number of hours provided, including specific timeframe.  An attendance log or similar document shall be maintained for Group Supported Employment”.  An attendance log or similar document is not required for ISE since the individual is competitively employed. 

E.1.i. – After group, Insert “for Group Supported Employment”.