Public Comments

DD Waiver Final Regulations

April 2019

 

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 on 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 in order 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:

   

  • 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.

    • Why some services and not others?

    • Consistency between the services does not exist.Group Day requires documentation of “observation of satisfaction”.

    • The requirement of semi-annual notes in the DSP supervision note regarding “satisfaction of the individual” or “observation of satisfaction of the individual” is not consistent with the already required individualized documentation.

    • If any one 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.

 

12VAC30-122-10. Purpose; legal authority; covered services; aggregate cost effectiveness; required individual and provider enrollment costs.

E.1 No back-dates payments shall be made for services that were rendered before the completion of the provider enrollment and the individual eligibility determination processes.

What if there are issues with the process when the family/legal guardian is renewing that is not discovered by support coordination or the provider until billing is denied?

 

12VAC30-122-100

D. ….When an individual is transitioning to a different provider, the former provider that served  said individual, shall at the request of the provider, provide all medical records and documentation of services to the new provider to ensure high quality continuity of care and service provision.

Please the following language, “ shall at the request of the provider, after written consent from the individual and/or guardian has been obtained….”

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.

 

4. Accept referrals for services only when staff is available to initiate services within 30 calendar days of the referral and perform such services on an ongoing basis.

 

What if an individual is initially given a start date and staffing is in place, however, changes at the last minute due to a situation out of the providers control?

              

9.d Providers shall prepare and maintain unique person-centered progress notes…. Such documentation shall be written on the date of service delivery, in instances when the individual does not communicate through words the provider shall note his observations about the individual’s condition and observable responses, if any, at the time of the service delivery.

 

Can this be within 24 hours, if using an electronic records system, and unable to access that record?

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

• 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.]

 

C. The following DBHDS licensed waiver providers shall ensure that new DSPs or DSP supervisors, including relief and contracted staff, …..

Please define who qualifies as contracted staff

 

 

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.

   

12VAC30-122-200. 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.

• 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.”

 

 

12VAC30-122-240. 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.

   

12VAC30-122-300 - 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 – 122-350 - Crisis Support service.

• The three-levels described here are not included in the other two crisis support services – they should be consistent.

   

 

12VAC30-122-380 - 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:

  • Participation in community volunteer opportunities or education programs;

  • 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

  • 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”.

• 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.

   

 

 

 

 

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”.

 

 

12VAC30-122-570 - 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.

Recommendation that WPA 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