The proposed regulations in Article 3. Administration, create multiple and direct conflicts with the statutes already enacted in Virginia Code §§ 37.2-500 through -512 which provide for the governance of CSBs and their executive directors/administrators, whereas it appears that these new regulations were intended to cover other types of providers, such as hospitals or private providers. We are therefore requesting that language be added to specifically excluded CSBs from the provisions of Article 3. Throughout the regulations, there are multiple references to disability specific chapters regarding requirements. As these chapters do not yet exist, it is hard to effectively evaluate in relation to these regulations. A full review of comments is not possible if the reference is made to the disability specific chapters and not being able to read them to obtain full context. There are definitions removed from proposed regulations that we are unable to determine if they will be included in the disability specific chapter or if being removed altogether which will impact practice. If duplications with performance contract remain in licensing regulations for the purpose of increasing structure for private providers, then we advocate removing redundant requirements in the performance contract. General Comments: 1. Continued reference is made to disability specific chapter – It would have been helpful to have them to reference back in the areas that reference them or site them related to a regulation. A full review of comments is not possible if the reference is made to the disability specific chapters and not being able to read them to obtain full context. When shall we expect the disability specific chapters? 2. Suggesting the regulations move to become gender neutral as positions could be filled by a male or female. 3. Any reference to “Substance Abuse” should be changed to “Substance Use Disorders” for consistency in terminology. 4. Multiple sections reference competency testing. This needs to be further defined including specification of expectations around this term. 5. Regulations feel like they are micromanaging and becoming prescriptive as to specifying exactly where information should be documented such as the face sheet as stating it should be in the individual’s record. Feels like every problem there was with a provider is now in the regulation Comments P Provide more information what are the “additional requirements related to disability specific services”? The definitions for the Initial Assessment and Comprehensive Assessment imply that these are two separate documents. Within DD services; the full comprehensive assessment is completed at enrollment to initiate services. This has an impact on same day access service This is where the comprehensive assessment is completed for the agency’s service. The definition is suggesting they are two separate assessments and there may not be a need to complete another assessment one-two weeks later when the person begins a service. The initial assessment is the comprehensive assessment. Recommending language such as “the comprehensive assessment may be completed at the time of initial assessment if it includes all elements of the comprehensive assessment.” "Case management service" or "support coordination service" Adding desires to case management service potentially broadens the scope of support coordination and possibly stretches limited resources. The service should be based on the individual’s needs. Add definition. of “Behavioral Health”, allowing for recognition of co-occurring MH/SU disorders and adjustment of license types Add def. of “Counseling” or other similar term (replacing counseling with it), to align w/ DMAS, which is describing counseling as psychotherapy and, therefore, would not allow counseling to be provided in places specified as acceptable under Licensing “Crisis Stabilization”-Recommending language change “…individuals may ‘be maintained’ in the community” to ‘be supported’. "Direct care position “-Clarification requested. Is this defining the role of a supervisor of direct care positions is also considered a direct care position? (ii) is confusing, is this saying that a supervisor of a direct care person is also referred to as a direct care position? “Full time employee” or “employee” Remove the second “employee” as this is seemed to state that only employees who work those hours are considered to be an “employee”. “Group home” : Is this still discussing IDD group homes, currently DBHDS has a group home licensed as a Therapeutic Group home for 16 individuals. CMS only allows 8 or less in the "group home" definition. If this is a way for DBHDS to become in line with CMS, what about the currently licensed programs that are greater than 8 clients? “Medication error” definition removed. What is the impact? Do we not have to investigate these as neglect? "Mental Health Community Support Service Skill Building" or "MHCSS- Consider aligning the acronym with the name of the service to improve clarity. Perhaps MHSB instead of MHSS. “Neglect”-Consider adding concept of intentionality to the definition “Outpatient services” definition “shall not include practitioners who hold a “licensed issued by a health regulatory board of DHP” or “who are exempt from licensing pursuant to” This reads as if licensed staff of excluded from providing outpatient services. ” Partial Hospitalization services”- DMAS does not specify that these services must be medically-directed. Remove “medically-directed” from proposed regulations. "Recovery"- The definition of Recovery for Substance Users is stigmatizing, especially in comparison to that of mental illness. DBHDS should be a role model in reducing stigma and this definition will be in regulations for years to come. Suggest using the SAMHSA definition for both mental illness and substance use recovery. A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Revise “Serious incident” Level II item 4 to clarify a TDO or unplanned medical hospital admission, as TDO is the conceptual equivalent. Is removal if Level III item 3 intentional? this section continues to be unclear and confusing: Better clarification is needed to address the following: *Incidents of violence * side effects of medications that require medical intervention, *Incarceration of the individual * injury that results in Permanent physical or psychological impairment. this language continues to be overly broad and unclear. how is a provider to assess consistently the "Level I serious incidents" do not result in significant harm to individuals, but may include events that result in minor injuries that do not require medical attention or events that have the potential to cause serious injury, even when no injury occurs”- this language continues to be overly broad and unclear. how is a provider to assess consistently the "potential to cause a serious injury when the event did not require medical attention? “Serious Injury”- while the individual is supervised by or involved in services, such as attempted suicides, medication overdoses, or reactions from medications administered or prescribed by the service. the withdrawal of this language would make the provider report on incidents that occur outside of the providers direct Supervision. Does this then apply to all outpatient clients not involved in direct supervision or a supervised setting? "Screening" “Screening for an assessment” is changing the concept of a screening. The attempt here is to change the meaning to align with the new definition for comprehensive assessment. "Supervised living residential service"- Change is currently recommended to be Staff is available on a 24-hour basis and provides daily monitoring. Recommend adding, “as appropriate based on ISP.” Rationale, this level of living is designed to assist individuals in community reintegration. This is best accomplished gradually and within a treatment plan. This should not be prescriptive but based on individual needs.