12VAC30-122-200. Supports Intensity Scale® requirements; Virginia Supplemental Questions; levels of support; supports packages.
• A.1- Delete “to 72” and add “or older” after “years of age.” If the SIS is only validated to age 72 then language should be added to automatically assign all individuals age 72 or older to Level 5, Tier 4. Level 5 is the highest level denoting significant need in general but not specifying it to medical or behavioral. Tier 4 is mid-range denoting significant need, which is appropriate for an aging population. However, there should be a statement that these individuals shall not be excluded from consideration of an individualize rate because of medical or behavioral needs.
• Recommend the addition of “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” to stay consistent with the CL application
• A.4.- DELETE. The specific scoring protocol should be in a Medicaid Memo, not in the
regulations.
• D – DELETE entre section/paragraph. This is a reserved section intended to explain the
establishment of supports packages as a profile of the mix and extent of services anticipated to be needed by individuals with similar levels, needs and abilities. Due to 2019 General Assembly budget language which prohibits the implementation of supports packages unless specifically authorized by the General Assembly, this section is not necessary.
• Add a new D – “Requires that the results of the SIS be provided within 10 days of scoring in an understandable format and that the service coordinated be required to explain the results and implications of the SIS score and avenues of appeal.”
• Add a new E.- “An automatic, independent review 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. Payment for covered services (tiers).
• A.4.e. – Modify the language to “The DMAS designee shall review each individual’s needs on at least.....” An individual’s needs are being reviewed not an individual themselves.
• 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.
• C 1: Recommend an increase to the $5,000 annual limit for environmental modifications from the current maximum annual cap of $5,000 to a level deemed appropriate to the cost of such modifications. This limit is years old and it is increasingly difficult for families and individuals to secure modifications that will allow them to remain in their homes over their lifespan for this small amount of funding. 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. This would allow greater flexibility for individuals to accommodate upfront costs of purchasing new environmental modifications without raising the overall multi-year dollar limits.
• C 3. Recommend an increase to the cost of electronic home-based supports from the current maximum of $5,000 per calendar year. This limit is not sufficient for up-to-date technology as well as any associated monthly monitoring fees. The purpose of these supports is to enable individuals who so desire to live more independently with less staff intrusion into their lives. The benefit should be consistent with the average cost of this type of support. 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. This would allow greater flexibility for individuals to accommodate upfront costs of purchasing new electronic home-based supports technology without raising the overall multi-year dollar limits.
• 4.b. The current application for customized Waiver rates requests data for the previous six months. If the provider has already served the individual for six months with a 1:1 ratio that is effectively supporting the individual to reduce behaviors, the provider should be allowed to submit data from the service period before 1:1 staffing began.
12VAC30-122-240. Services covered in the Building Independence Waiver.
• Add Agency and CD Companion and Personal Assistance, and Individual & Caregiver Training to the BIS waiver. With the addition of these services, there may be more interest in utilizing this lower cost waiver by persons on the Priority 1 waiting list.
12VAC30-122-250. Services covered in the Community Living Waiver.
• Add Family and Caregiver Training. This service is applicable to all individuals and families and should not be limited to the FIS waiver.
12VAC30-122-260 – Services covered: Family and Individual Support Waiver.
• Add Independent Living Services to the FIS waiver. This service can assist individuals living on their own or wishing to live on their own.
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.
12VAC30-122-280 - Benefits Planning Services (reserved).
• This service is now available (Medicaid Memo Sept. 4, 2018). It should be included in the final DD Waiver regulations out for public comment.
12VAC30-122-300 - Community-based crisis support service.
• After means add “planned crisis prevention and emergency crisis stabilization services provided to”; strike “a service”. This brings it in line with Center-based Crisis.
12VAC30-122-310 - Community coaching service.
• A- After barriers add “or to support an individual’s participation when there is an ongoing barrier to participation” See definition.
• C.3- Strike “This service shall not be provided within a group setting.” This sentence is not necessary and has the potential the individual from learning how to interact and communicate with others in a community engagement setting – the entire purpose of the service. Requiring the service to be one-on-one is sufficient.
12VAC30-122-320 - Community Guide Service. (reserved);
• This service is now available (Medicaid Memo Sept. 4, 2018). It should be included in the final DD Waiver regulations out for public comment.
12VAC30-122-340 - Companion service.
• C.1- Strike second sentence and limiting the service to eight hours per 24-hour day. While the occasions might be rare, this service can support those who can otherwise function reasonably independently at a modest cost – the 8 hour per day limitation can interfere with that. The waivers already allow a combination of various services to flexibly accommodate an individual’s needs. Companion services are inexpensive and there may be times when an individual requires more than eight hours of this service in a given day. The authorization should be an annual amount or hours that can be used as the individual needs them. Eight hours per day is an arbitrary cap.
• D.4.b- Replace with “Providers that are licensed by DBHDS, a supervisor meeting the requirements of 12VAC35-105 shall provide supervision of direct support professional staff.” This brings it in line with other similar services.
12VAC30 – 122-350 - Crisis Support service.
• The three-levels described here are not included in the other two crisis support services – they should be consistent.
      
12VAC30 – 122-360 - Electronic Home-Based Support Service.
• B.1.- STRIKE “physically”. The section notes that the individual must be “physically” capable of using the equipment provided via EHBS service. Some EHBS services may be voice activated and not require physical manipulation. Although voice activation could be considered “physical”, this provision could be misunderstood and, thus, misapplied by authorizers or auditors.
• C.1. Recommend an increase to the cost of electronic home-based supports from the current maximum of $5,000 per calendar year. This limit is not sufficient for up-to-date technology as well as any associated monthly monitoring fees. The purpose of these supports is to enable individuals who so desire to live more independently with less staff intrusion into their lives. The benefit should be consistent with the average cost of this type of support. 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. This would allow greater flexibility for individuals to accommodate upfront costs of purchasing new electronic home-based supports technology without raising the overall multi-year dollar limits.
12VAC20-122-370 - Environmental Modification Service.
• C.2. Recommend an increase to the $5,000 annual limit for environmental modifications from the current maximum annual cap of $5,000 to a level deemed appropriate to the cost of such modifications. This limit is years old and it is increasingly difficult for families and individuals to secure modifications that will allow them to remain in their homes over their lifespan for this small amount of funding. 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. This would allow greater flexibility for individuals to accommodate upfront costs of purchasing new environmental modifications without raising the overall multi-year dollar limits.
• C.6.- We recommend that an exception process be put into place for the uncommon circumstance in which the expansion of square footage to the home (which is prohibited) is an incidental result of a modification that will enable the individual to remain in the home ( e.g. a larger, accessible bathroom). Limits could be put into place for how much additional square footage would be allowable in an exceptions process.
12VAC30-122-380 - Group Day Service.
• B.1. Support the addition of the following that are included in the new CL waiver renewal application but are not currently included in the proposed final regulations:
o Participation in community volunteer opportunities or education programs;
o Staff coverage for transportation of the individual between service activity sites.
Transportation is included as part of the service. The provider may be reimbursed for the
time spent transporting the individual to community locations as part of the waiver billing o Personal types of activities (i.e. assistance with ADLs). These allowable activities are
critical for individuals that need them but are not necessarily “skill building”.
o Allowable activity of “providing safety supports in a variety of community settings”: This
allowable activity is not 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 nor in the “2016” version of regulations. These refer to activities rather than the requirement for skill-building; this phrase offers more flexibility for providers who are spending significant time in personal care than in skill-building. Consistent language should be included in these proposed regulations.
   
• C. Add 6. Recommend annual allocation for Group Day and Community Engagement hours to allow increased flexibility. Currently, Group Day hours and Community Engagement hours are authorized on a monthly basis with additional estimated “flex hours”. We recommend that there period of authorization be lengthened to allow more flexibility and consumer choice. For example, individuals choose whether they want to go out in the community or stay in a center on any given day. Because of weather or other personal circumstances of the individual, the individual may want to stay in the center more often in the winter and in the community more often in the Spring/Summer/Fall. Hours could then be drawn from a quarterly, semi-annual or annual “pool” of hours based on their person-centered plan.
• D.5. Supervision - There is NO reference to Licensing regulations to define “supervisor.” Licensing does not define a “supervisor” but does define a QDDP. 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, but 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 when defining QDDP since there are numerous QDDP responsibilities within these regulations.
12VAC30-122-390 - Group Home Residential Service.
• E.1.c- Change “at least a daily note” to “a Progress Note”. This makes it consistent with other requirements. See previous comments under “General Comments”.
• Move C.3 under letter D. It is under this section in other service descriptions. 12VAC30-122-400 - Group and Individual Supported Employment Service.
• Add Employment Services Organizations (ESOs) as qualified providers of Employment & Community Transportation Services.
• Add Employment Services Organizations (ESOs) as qualified providers of Peer Mentor Support Services.
• Add Employment Services Organizations (ESOs) as qualified providers of Community Guide Services.
• A.3.a. – Strike “limited” after but reimbursement shall not. (2nd sentence, 4th line)
• B.1. – Add “and enrolled in school” after for individuals younger than 22 years of age. Strike “for
the individual enrolled in the waiver”.
• 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 that 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 Change to “concurrently with other waiver services for purposes of job discovery”. Should read as follows: “For time limited and service authorized periods (not to exceed 24 hours) individual supported employment service may be provided in combination with concurrently with other waiver services for purposes of job discovery.” This revision helps with clarity.
     
• 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.
• 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”. 12VAC30-122-410 - In-Home Support Service.
• C5- Add “Back up plan may include agency support”. This is the most viable option for individuals who do not have a primary caregiver. While not specifically stated in the current regulations, families and individuals have historically been advised by case managers that the back-up plan must be a family member. Since an agency is providing the in-home service, it makes sense that a provider could also provide the back-up support. But, it should be optional and clarified that it is an option.
• Recommend that In-Home Services hours be authorized quarterly, semi-annually or annually – a “pool” of hours that would include and accommodate “periodic support hours”. Current regulations do not limit adding an average number of “periodic support hours”. However, in practice, this is an ongoing implementation issue with additional flexible hours not being approved. A longer period of authorization would help allow flexibility when an individual must stay home from group day or employment, community engagement. Most importantly, it supports choice.
12VAC30-122-420 - Independent Living Support Service.
• A – Add following receiving this service “lives, or is preparing to live, alone . . .”; strike “typically”. This service should be available to those planning to transition to more independent living and not just those already living independently.
• A- Add “or FIS waiver” at the end of the last sentence. There are individuals that wish to live independently in the FIS waiver who wish to live independently, particularly transition age you who could benefit from this service. It should not be limited to those already in an independent living setting.
• C.1.- Add “If the hours consistently exceed 21 hours per month, the individual shall be immediately eligible for a reserve slot.”
• E.1.c. – add “observations of individual’s responses to services shall be available in Progress notes”
• E.1.d – strike “and the documentation will correspond with billing” 12VAC30-122-430 - Individual and Family/Caregiver Training Service.
• A- Strike “FIS waiver” Add “in all of the DD waivers”. There is no reason that it is only included in the FIS waiver. Individuals and their families can benefit from this service.
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