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 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 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.
? If anyone 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.
• 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. 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.
• 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]
• 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.

12VAC30-122-80. Waiver approval process; authorizing and accessing services.
• C.3.- add at the end “and other service plans as applicable.”
• C.4.- Following initiated within change “30 days” to “90 days,” 
• C.6.c.- Following approve change “suspend” to “pend” which is the terminology currently utilized when seeking more information.

12VAC30-122-120. Provider requirements.
• 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 “Such documentation shall be written on the date of service delivery.” This is not in keeping with the definition of Progress Note in 122-20 and as referenced earlier in comments.
• 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. 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, describe the process of approval, and include a list of approved standardized tests and resources for providers. 

C5. The orientation is a knowledge-based assessment, while the competencies are both knowledge and action based. On many of the competencies, you are required to assess action and knowledge. Where I have found the deficiencies to be is in the action part of the competencies. Therefore, retaking the orientation test is not a valid way of training for action. Having statewide readily available online training tools for the competencies from department would be helpful.

• D.1- The reference should to the “personnel file” not the “provider record”
• D.2- Change sentence to “Completed documentation from the online certificate shall be maintained in the Personnel File.”
• E.7- Add “only” before specific to the needs; and following specific to the needs strike “and level”
• E.8- add “only” before “specific to the needs”; strike “and service levels”. These changes clarify the intent have the advanced competencies applicable as the needs of the individual requires.
12VAC30-122-190. Individual support plan; plans for supports; reevaluation of service need.
• A.8- Add “by the support coordinator” before with a copy of the. This clarifies that the support coordinator is responsible for providing a copy of the ISP to the individual family.
12VAC30-122-120. Provider requirements.
• 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 “Such documentation shall be written on the date of service delivery.” This is not in keeping with the definition of Progress Note in 122-20 and as referenced earlier in comments.
• 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. 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, describe the process of approval, and include a list of approved standardized tests and resources for providers. • C5. The orientation is a knowledge-based assessment, while the competencies are both knowledge and action based. On many of the competencies, you are required to assess action and knowledge. Where I have found the deficiencies to be is in the action part of the competencies. Therefore, retaking the orientation test is not a valid way of training for action. Having statewide readily available online training tools for the competencies from department would be helpful. • D.1- The reference should to the “personnel file” not the “provider record”
• D.2- Change sentence to “Completed documentation from the online certificate shall be maintained in the Personnel File.”
• E.7- Add “only” before specific to the needs; and following specific to the needs strike “and level”
• E.8- add “only” before “specific to the needs”; strike “and service levels”. These changes clarify the intent have the advanced competencies applicable as the needs of the individual requires.
12VAC30-122-190. Individual support plan; plans for supports; reevaluation of service need.
• A.8- Add “by the support coordinator” before with a copy of the. This clarifies that the support coordinator is responsible for providing a copy of the ISP to the individual family.
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 monthly with additional estimated “flex hours”. We recommend that the 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.
 

12VAC30-122-400 - 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”.

12VAC30-122-460 - Personal assistance service.

• A.3. – Add “Personal Assistance can be provided simultaneously with supported employment services and can be billed concurrently”. The provision currently states that an additional component of personal assistance services is to aid and supports to individuals in the work place, with the final sentence stating, “Work related personal assistance service shall not duplicate supported employment service.” The addition of the suggested sentence at the end of this section clarifies that both can be provided at the same time and that they are distinctly different services.
• A.4- Change to “in all DD waivers”. As previously stated, it is unclear why this service is not available in the BI waiver. Individuals in the BI waiver are more likely individuals with physical developmental disabilities who may require personal assistance services in order to live independently in their homes. PA services can be critical to this population.

12VAC30-122-570 - Workplace Assistance Service (12VAC30-122-570).
• B.4. – Add (e) at the end of the lettered list which adds “Phone, media and in-person contacts with a Job Coach” as an allowable/billable activity. There may be times when a workplace assistant may need to consult with the individual’s job coach in order to meet the needs of the individual and to ensure consistency of strategies to support the individual to be successful in the workplace.
• D.3. – Providers of Workplace Assistance that are CARF accredited employment vendors of DARS satisfy staff competency requirements for Workplace Assistance Services.
• Recommend that Workplace Assistance Services be added to the BI Waiver as individuals on this Waiver may have health and/or safety monitoring needs in a place of employment.