ITC of VA Practice Manual, page 194, 'Medicaid Early Intervention Services Program Reimbursement Information' table. Please revise the typo (145.50/mo) and change to 148.50/mo.

CommentID: 237475

Adler Therapy Group appreciates the opportunity to comment on the proposed updates to the Virginia Early Intervention Practice Manual. We respectfully recommend revising the current five (5) business day requirement for entering contact notes into TRAC-IT to seven (7) business days following the date of service.

Our agency’s documentation workflow requires therapists to complete notes within five business days, followed by a brief agency quality review to ensure completeness and compliance before mass uploading to TRAC-IT. The current five-day limit compresses both steps into the same period, which increases the risk of errors and rushed documentation.

Therapists within the Early Intervention system are already managing full caseloads while traveling extensively across cities and communities to provide in-person contact visits and fulfill other required duties such as family communication, coordination, and reporting. Given these demands, further shortening documentation time requirements would create an undue burden on providers who are already working at or beyond capacity. Any change to documentation timelines should consider the workload of therapists to ensure that service quality, accuracy, and staff well-being are not compromised.

Proposed language:
“All Early Intervention service contact notes must be entered into TRAC-IT within seven (7) business days following the date of service.”

Rationale:

• Improves documentation accuracy and compliance
• Supports agency quality review and efficient data management
• Maintains timely documentation without delaying service coordination
• Reduces undue burden on therapists with already full caseloads

We believe this modest extension preserves accountability while allowing agencies to maintain high-quality, accurate records without overburdening staff.

Thank you for considering this recommendation as part of the Practice Manual update.

To the Practice Manual Review Committee,

Thank you for the opportunity to provide public comment on the revised Virginia Early Intervention Practice Manual!

I am a speech-language pathologist/early intervention provider in Virginia, and I am writing specifically about the “Assistive Technology” section.

Under this section (Chapter 7, page 5), the current draft states:

“First consider or try simple, low- or non-tech modifications or solutions and then build up to mid-tech and to high-tech modifications or devices as needed.”

I respectfully request that the committee consider revising this sentence. As written, it implies a required progression from low-tech to high-tech AAC, which is not consistent with current evidence-based practice or ASHA guidance regarding augmentative and alternative communication (AAC).

Rationale

1. Current best practice emphasizes feature matching—not a low-to-high-tech hierarchy.
ASHA’s Practice Portal states that AAC assessment should be based on feature matching: selecting tools and systems according to the individual child’s strengths, needs, and environments. This approach does not require “starting” with low-tech before moving to more robust options.

2. Evidence supports early access to robust, high-tech AAC when indicated.
Research shows that children with complex communication needs benefit from early AAC access—including high-tech speech-generating devices (SGDs) in toddler and preschool years. Delaying high-tech AAC until lower-tech options have been “tried first” is not an evidence-based requirement and may actually slow a child’s communication and language development.

3. Presuming competence and the “least dangerous assumption.”
AAC best practice emphasizes presuming competence and applying the least dangerous assumption—making decisions that minimize the risk of limiting a child’s learning opportunities. A mandated low-to-high-tech progression can inadvertently require children to “prove readiness” at lower-tech levels before accessing a robust system. This is particularly concerning for children with limited or unreliable speech who need a full, generative language system from the start.

4. Practical implications in Virginia EI (Part C).
A statement that appears to require starting with low-tech solutions can unintentionally:

• Delay appropriate referrals for high-tech AAC trials or funding,
• Create confusion about eligibility or “readiness,” and
• Pressure providers to follow a stepwise hierarchy even when their clinical judgment, family input, and evidence indicate that a high-tech option is the most appropriate starting point.

In my own caseload, more than half of the children I serve require some form of AAC beyond simple, low-tech supports. For many families, high-tech AAC (e.g., a robust speech-generating device app on a tablet) has been the most effective and functional way to support communication progress during daily routines.

Suggested Alternative Language

If the committee wishes to retain language about considering the full range of technology, I recommend wording that reflects feature matching and avoids implying a required progression:

“Teams should consider a full range of assistive technology options, including no-tech, low-tech, mid-tech, and high-tech AAC. Decisions should be based on an individualized, feature-matching assessment of the child’s strengths, needs, environments, and family priorities. There are no prerequisite skills or required steps (e.g., success with low-tech) before considering high-tech AAC when a more robust system is indicated.”

This language is consistent with Virginia’s flexibility around assistive technology while aligning more closely with ASHA guidance and the broader AAC evidence base.

Thank you again for inviting public comment and for your continued work to ensure that Virginia’s Early Intervention system reflects best practices and supports young children with complex communication needs and their families.

Sincerely,

Mariam Cherry, M.S., CCC-SLP

Speech-Language Pathologist

Cherry Blossom Speech, PLLC

Chapter 4, page 23, item 5.a.4 states "Use of the ASQ-SE or another social-emotional-specific screening tool is strongly recommended for all children, in addition to the comprehensive screening tool, as part of the initial eligibility determination process. It is strongly recommended that no child be found ineligible for early intervention without completing the ASQ-SE or another social-emotional-specific screening tool."  Comment:  The addition of a required screening tool (ASQ-SE) must be accompanied by additional funding to support purchasing the tool and training staff to use it ."

Chapter 6, page 56, item 4.f states "Strongly recommended: If the ASQ-SE was completed during eligibility determination and results were in the monitoring zone or above the cutoff, the assessment for service planning should include the use of a social emotional-specific assessment tool. …..  It is strongly recommended that the assessment for service planning team includes a practitioner with infant mental health expertise (social worker, counselor, psychologist) or a practitioner with Infant Mental Health endorsement at the Family Specialist Level or higher for those children with ASQ-SE results in the monitoring zone or above the cutoff or when other risk factors are present. :  Comment:  To meet the "strongly suggested" expectation of completing a specific social emotional assessment tool, local systems will need additional funding to support purchasing a tool and training staff to use it.  Further, to include a practitioner with infant mental health expertise or endorsement will require significant investment in personnel preparation.  Many communities lack access to such personnel and will not have capacity to meet this expectation.  We look forward to understanding the plans for expanding the cadre of personnel who can meet these qualifications and how funding will available to support added staff. 

Chapter 7, page 70, Specific requirements related to physician signature states:  "if an IFSP is not signed by the physician, physician’s assistant, or nurse practitioner within 30 days of the first IFSP service other than service coordination, then services provided prior to the date the IFSP is certified (by the physician, physician’s assistant, or nurse practitioner) will not be reimbursed by Medicaid or Part C."  Comment:  Local systems are hampered in meeting this requirement by families who can't afford to or choose not to take children to the pediatrician and pediatricians refusing to sign if they haven’t seen the child within a specific period of time.  We are required to provide the service but unable to access reimbursement regardless of how much we encourage the family to take the child to the pediatrician.  Part C funds should be available to support services with documentation of effort to acquire physician certification.

Chapter 9, page 148, General rules for documentation #13 states:  "Complete contact notes and enter/upload notes to TRAC-IT in a timely manner, no more than 5 business days from the time of the contact."  Comment:  Local systems using monthly data uploads are unable to meet the expectation of entering or uploading documents within 5 days.  Please consider language that continues the allowance for less frequent data uploads. 

Chapter 11, page 162, Early Intervention Rates. Comment:  Two references to a rate of $168.75, correct rate is $168.76 

Chapter 11, page 162, Early Intervention Rates.  Comment:  Published rates are insufficient to sustain a quality workforce.  Recommend a comprehensive rate study that results in increased rates with a plan to review adequacy on an annual basis.

Chapter 11, page 164, Application of Rates.  Comment:  Three references to a rate of $168.75, correct rate is $168.76.

Chapter 11, page 187 Comment:  Reference to ITOTS, should read TRAC-IT 

Chapter 11, page 194 Comment:  T2022 correct rate should read $148.50 

Chapter 6, public comment version page 56, 4,f: Specific Language: It is strongly recommended that the assessment for service planning team includes a practitioner with infant mental health expertise (social worker, counselor, psychologist) or a practitioner with Infant Mental Health endorsement at the Family Specialist Level or higher for those children whose ASQ-SE results in the monitor zone or above the cutoff or when other risk factors are present.  Comment: The "strongly suggested" expectation may be difficult for rural areas with limited provider options-thus potentially effecting timelines to complete assessment/IFSP.  We typically determine ASP teams based upon a family's concerns and priorities.  Example: If the concern is feeding we would have an OT or ST plus an Early Intervention Professional-who is an employee of the LLA.  It will be an additional expense to local systems for children who have private or no insurance to bill.  

We currently have an OT and DS who have other education, training and experience in supporting children's social/emotional development.  I would recommend making the practitioner guidelines broader. 

Chapter 7, public comment version page 70, Specific Language: If an IFSP is not signed by the physician, physicians assistant or nurse practitioner within 30 days of the first IFSP service other than service coordination, then the services provided prior to the date the IFSP is certified, will not be reimbursed by Medicaid or Part C.  Comment.   Many families can't afford or choose not to take their children to the doctor even after much encouragement from service coordinators.  Doctors will not sign the IFSP if they haven't seen the child within a specific timeframe.  While making attempts to get the the physician cert signed, Part C funds should be available to reimburse contracted providers.  They will not provide  the entitled service for free or may want to wait to begin services until after the physician cert is signed, thus potentially going over the 30 day timeline to begin services. 

Chapter 9, public comment version page 148, Specific Language: Complete contact notes and enter/upload notes to TRAC-IT in a timely manner, no more than 5 business days from the time of the contact.  Comment. Local systems using monthly data uploads are unable to meet the expectation of uploading documents within 5 days.  Please consider language that continues the allowance for less frequent data uploads.  

Chapter 6, Page 56, Item 4.f –

We recognize the value of using targeted assessment tools and involving practitioners with infant mental health expertise. However, implementing this recommendation presents significant challenges for many local systems. Specifically:

• Funding constraints: Purchasing specialized assessment tools and training staff in their use requires dedicated funding that is not currently available in many communities.
• Workforce limitations: There is a shortage of practitioners with infant mental health endorsement, particularly in rural and underserved areas. Without a clear plan for workforce development, this recommendation may be unattainable for many programs.

The Practice Manual & TRAC IT

The Practice Manual, page 2, states: TRAC-IT (Tracking, Reporting and Coordinating for Infants and Toddlers) is Virginia’s statewide early intervention data system. The Practice Manual assumes early intervention steps are being completed directly in TRAC-IT. However, references to “completing” a task in TRAC-IT allow that it may be completed through direct data entry or an electronic health record (EHR) upload.

Since it is expected that “early intervention steps are being completed directly in TRAC IT”, then TRAC IT should be in line with the Practice Manual and vice versa. Currently, the following areas are not consistent:

1. Declining EI Services form – throughout the Practice Manual, the Declining EI services form is listed as “optional.” This form is not available consistently, or ever as a stand alone form, within TRAC IT and making it an optional form is confusing for staff. References to Declining EI Services can be found on page 11 – 12d; page 35 4a; page 72 – 7c; page 73  - 8a; page 119 -12c and 13 a; page 127 – 17c; and page 128 – 18a. Recommend adding a stand alone Declining EI Service form to TRAC IT or removing completely from the Practice Manual.
2. Eligibility Determination – if a child is found eligible due to medical records, it is not possible to update the eligibility determination form at the assessment for service planning meeting as described in Chapter 4: Intake and Chapter 6: ASP without requiring the family to sign an additional Notice and Consent for Eligibility Determination. The Practice Manual should reflect processes that are available in TRAC IT. Recommend separating the Notice & Consent for Eligibility Determination and Eligibility Determination form as two separate tasks in TRAC IT to align with the practices described within this draft of the Practice Manual.
3. Physician Certification letter and IFSP Summary letter as referenced in Chapter 7, page 69, 5b and 5c. TRAC IT does not contain a Physician Certification letter or IFSP Summary letter. Recommend adding both to TRAC IT as it is described in the Practice Manual.
4. Chapter 9 EI Record, General Rules for documentation page 148 – 7, 8, and 14 – if documentation is completed directly in the record, then handwritten should not be an option for contact notes. Recommend deleting the handwritten option.
5. Chapter 9 EI Record, Access to Records page 150 – 5; this indicates that a record must be kept on the “Access to Record form” which does not exist in TRAC IT. Recommend adding to TRAC IT as it is described in the Practice Manual.

Errors / Information that is Incorrect/Outdated

Chapter 7, IFSP Instructions, General Information, page 77, 4^th bullet references Section V of the IFSP which is an old numbering system. Should reflect Services section of IFSP. Recommend removing reference.

Chapter 11, Finance, page 187 references ITOTS – should be TRAC IT. Recommend changing reference.

Chapter 11, Finance, Early Intervention Rates, page 162 – incorrect rates for audiologists; page 164 -6 – incorrect EI rate, page 194 – T2022 incorrect EI rate. Recommend updating to correct EI Rate.

Financial Implications

Chapter 4 Intake and Chapter 6 ASP both strongly recommend the use of additional social-emotional screening and assessment tools. While this is best practice, there are direct financial costs in purchasing new assessment materials and training new staff. It would be helpful to have additional funding to support these activities. Recommend changing the language in the Practice Manual or seeking funding to support best practices.

Chapter 7 IFSP Development, page 70 – it is increasingly difficult to obtain physician certification despite multiple attempts to get the IFSP certified due to staffing shortages at the pediatric offices. Recommend removing the restriction from using Part C dollars when good faith efforts are made and documented.