Recommended Change #1:  In Section C. 3., "telephone communication" should be deleted from the list of in-kind activities that cannot be billed.

Reason for Change: Telephone communication is considered an allowable activity in B. i.

Recommended Change #2:  In Section B. i., the phrase "or via video conferencing" should be added at the end. 

Reason for Change: The would clarify that video conferencing is an allowable activity in the provision of Therapeutic Consultation services. Allowing video conferencing might increase the availability of Therapeutic Consultation services, especially in rural areas.

Recommended Change #3:  All of C. 4. ("Therapeutic consultation shall not be billed solely for purposes of monitoring the individual") should be deleted.

Reason for Change:  Page 79 of the December 2018 DOJ Monitor's report states "... of those who did have BSPs, half were not supervised by qualified behavior clinicians." The current language in the regulations suggests that monitoring of an ongoing Behavioral Support Plan (BSP) is not an allowable activity. In fact, ongoing monitoring (that is, supervision by a qualified clinician) of an individual's progress is essential if the plan is to be successful. The language in C.4. suggests that this monitoring is not permitted. 

Recommendations to therapeutic consultaiton services:

1.  Reclassify Positive Behavior Support Facilitators and Certified Recreational Therapist to billing code 97139.

2. Remove telephone calls form non-billable activity.

3. Permit video chat and conferencing - this will help provide services to the rural area or underserved populations and even in urban areas where travel time is a barrier between services.

4. Allow Certified Occuaptional Therapy Assistants, COTA's who are certified by the Commonwealth, to work under the supervision of Occupational therapsit. COTA could be billed at 97530 and OT's will use code 97139.

5. Therapeutic consultation should be allowed under all Wavier programs, inclduing ICFID.

6. Make all documentationa billable activity.

7.  All therapeutic consultantants should recieve a 5% raise to be comaprable to the commercial industry.

8. Standarization of documentation, either in written forms or EMR.

9. Expand therapy services to incldue psychiatry and nurse pracitioner for medication managment.

10. Allow Positive Behavior Support Facilitators, PBSF to have a Positive Behavior Support Assistant, PBSA mirroring the BCBA protocol.

12VAC30-122-200

RE: 12VAC30-122-200.

Section A.1. states: "The SIS® is an assessment tool that identifies the practical supports required by individuals to live successfully in their communities. DBHDS shall use the SIS® Child for individuals who are five years through 15 years of age. DBHDS shall use the SIS® Adult for individuals who are 16 to 72 years of age. Individuals who are younger than five years of age shall be assessed using either the SIS® or an age-appropriate alternative instrument, such as the Early Learning Assessment Profile, as approved by DBHDS"

Recognizing that there are adults receiving waiver services who are over the age of 72, what is DBHDS planning to use as an assessment tool when considering support levels/tiers going forward? Are there other means-tested tools available? If not, will this have an impact on tier adjustments? 

The Waiver says that we have more transportation options but we do not in Roanoke VA. Also, you need to make sure the Waiver is equal for every one. My understanding was that one of the purposes of combining DD with ID was to make sure that everyone had the same access to all available services. This is not holding up to be a true statement. The DD population needs to have more living in the community options and more public transportation options so that we are not restricted at 8:15pm to go out in the community. 

Section 12VAC30-50-490 (E) Qualifications of Providers, Number 3:  States:

3. Support coordination/case management services shall not be provided to the individual by:  (i) parents, guardians, spouses, or any family living with the individual, or (ii) parents, guardians, spouses, or any family employed by an organization that provides support coordination/case management for the individual except in cases where the family member was employed by the case management entity prior to implementation of these regulations.

I would like to express my concern that the final statement in this clause (ii), originally introduced in the emergency regs and redefined here, creates a hardship for the individuals with ID/DD who live in rural or semi-rural areas where there is little to no choice of case management providers.  In many areas of the state, there may be only one CSB within a reasonal driving distance.  12VAC30-50-490 also clearly states that individuals with ID/DD have the right to chose their case management provider, but if that individual has a family member who works for the local CSB in any capacity (mental health, early intervention, ID/DD services, etc), the main provider for ID/DD case management is eliminated as a choice for that individual.

The inital part of this regulation (i), stating that support coordination should not be provided by family members of an individual, should be sufficient in ensuring authentic and ethical service delivery.  Please consider removing (ii) to ensure that all individuals with ID/DD have sufficient choice in case management regardless of where their family members are employed.

I propose that telepractice patforms be incorporated into Therapeutic Consultion services to aid in providing more serivces to the rural and urban areas where distance and time spent travling impeads service deliverly. Telepractice can be used safely and HIPAA compliant with the appropriate platforms, especialy in caregiver training, assessments and observations.  

T

I wanted offer comment to the proposed regulation indicating that the quarterly reviews need to be in the individual’s record no later than 15 calendar days from the date the review was due to be completed.  This is a concern for Case Managers/Support Coordinators as they need to receive and review the providers quarterly reviews  incorporating  the information in their review.

There are occasions in which the provider is late or does not provide quarterly documentation at all, even with numerous follow up by the CM/SC.  This regulation will prevent the CM/SC an opportunity to review the provider quarterlies and synthesize the information as needed.  It would also create a potential citation for not meeting a regulation when it is not within their control.

Can the regulation be edited to offer a period of time for the CM/SC to review provider quarterlies and then complete the Case Management quarterly?

The Arc of Northern Virginia and other disability advocacy organizations in Northern Virginia routinely meet to share information and concerns.  This coalition of organizations is named The Virginia Ability Alliance, and we focus on ensuring all people with disabilities are living a full life in their homes and communities.  Our organizations collectively serve many thousands of Northern Virginians with developmental disabilities (DD) and their loved ones.  On a frequent basis, we all field inquiries about Medicaid Waivers and the cadre of DD service options in Virginia. 

These contacts with families have helped us learn a tremendous amount about how the previous regulations for the Waivers and the current emergency regulations have impacted the ability of people with disabilities to access critical services and supports.  The new regulations and Waiver system are a significant improvement from the previous system. Having seen the new regulations in use since fall 2016 has given us the opportunity to find ways in which they could be further improved.

The comments below are representative of our joint concerns with the current regulations and, where appropriate, include proposed remedies to the issues cited.  We look forward to working closely with DBHDS at every opportunity to assist in having needed adjustments made to the DD Waiver Regulations.

The DD Waivers Waiting List

Though the funding for DD Waivers is beyond the control of DBHDS, the long and continuously growing waiting list to access the DD Waiver is a foremost concern of our organizations.  We would support any consideration of a contract that would not allow a waiting list for basic care services.

For individuals on the waiting list, we have growing concerns about the age of the primary caregiver(s) not being considered in assessing waiting list priority.  Since the new regulations have been in effect, we have seen rapidly growing panic from aging caregivers who no longer qualify for the Priority One waiting list due to age.  It creates tremendous stress for the caregivers and loved ones.  We have done ourselves a disservice in planning as it is obvious that caregivers in advanced age, no matter how healthy, are going to reach a point in the near future when help is critical.  The removal of this eligibility for Priority One reduces the odds that the person with a disability will be able to access services before their caregiver dies.  This is setting up the person with a disability for a series of rapid crises, as they lose parents, navigate the service system, and, in many cases, move to access services they need.  We propose that the age of the caregiver again be considered as a factor in determining eligibility for Priority One of the waiting list. 

The terminology used in association with the Priority tiers is confusing and misleading.  To explain these categories in terms of years someone could be expected to wait for services furthers the notion that our system will always have multiple years of wait time for assistance.  It frames our future in a negative light and is disrespectful to people who are eligible for assistance immediately, but who have been failed by our state’s continuous failure to budget appropriately.  Additionally, the usage of years of wait time confuses families who often feel it is a guaranteed maximum waiting time. 

For individuals who need to transfer from one Waiver to another Waiver offering a higher level of services, urgency of need should be taken into account.  Though anyone in this situation is in need, there are people on that list who have emergency needs (e.g., death of all caregivers or behavioral crises) and people who need a higher level of service but may be able to wait a short period of time (e.g., parent who is struggling to lift them and perform needed personal care at home).  A system to assess that urgency and award reserve Waiver slots accordingly would be a better solution.  If no one is currently on the reserve list at a given CSB when a slot becomes available, that slot should be made available to the person highest on the Priority One waiting list.

Assessment for services

The DMAS-62 form that scores someone’s medical needs and eligibility for hours of nursing care under the DD Waiver system does not include all possible medical needs.  Some people with complex and unusual needs are not able to get nursing hours their care team recommends, as the needs are not reflected on the form.  The regulations should clarify that the advice of the providing medical team should be taken into account in determining nursing hours.

There is heavy reliance upon the Supports Intensity Scale (SIS) in determining service availability, with all indications that such reliance will increase in the future.  Like all assessments, it is imperfect in seeing the full picture of someone’s life.  Because specialists (e.g., medical and behavioral providers) have invaluable insights into the support needs of individuals they serve, their written statements should be taken into account, along with SIS responses, to determine final SIS scores.  SIS scores should be able to be appealed when the SIS fails to take into account critical care information not captured in the assessment.

Waiver and Service Eligibility

People with the DD Waivers do not have the option to “spend down” income over the Waiver income cap on medical expenses to demonstrate eligibility for Waiver.  The net result is that people with either high earned or unearned income are ineligible for the DD Waivers.  As we see the generation of baby boomers retiring and SSDI payments to adult children reaching and exceeding the limits of financial eligibility, it would be wise to amend the DD Waiver Regulations to allow a “spend down” option similar to that allowed under the CCC Plus Waiver.  Additionally, regulations should protect eligibility for anyone who is put over the monthly income cap as a result of SSDI received from parents.  This benefit cannot be refused, despite the wishes of the person with a disability, yet it can have the effect of making them ineligible for crucial services they cannot afford.

Service Conflicts

The proposed Waiver regulations prohibit the same person from receiving both Private Duty Nursing and Skilled Nursing.  This has been a concern for families whose loved ones using Waivers have significant nursing needs that require ongoing nursing care through PDN, but also significant skilled oversight that realistically only comes with a nursing case manager.  If the regulations were to allow limited hours of Skilled Nursing for those people whose nursing needs are beyond what can reasonably be covered with the limited oversight funded in the Private Duty Nursing rate as demonstrated by history, it would prevent institutionalization for some of the most medically at-risk individuals in our system. 

The proposed regulations do not allow personal care to be billed in conjunction with skilled nursing.  For individuals who receive both services, this is a challenge.  It is not reasonable to ask that an individual with Waiver having a nursing come for a brief nursing visit would be able to have their personal care attendant leave during that time and return once the nurse leaves, or to sit by without pay during the visit.  The problem is compounded as personal care attendant is the person who will be able to provide private personal care that the nurse may not be best suited to giving during the visit.  We suggest allowing some overlap of billing for times when skilled nurses are making brief visits and regularly scheduled personal care is still needed.

The Waiver regulations allow the use of personal care attendants in combination with group or individual supported employment, unless the individual is living in a group home or sponsored residential situation.  This loophole creates an unnecessary hurdle to accessing employment for people living in either group or sponsored residential situations.

Regulations should clarify that, for individuals needing a personal care attendant with them while accessing community guide services, service overlap should be allowed as the community guide does not provide personal care supports.  For similar reasons, community engagement should allow for the simultaneous provision of personal care services. 

Service Definitions and Regulations

The eligibility for center-based crisis and community-based crisis services mandates a history of involvement with psychiatric hospitalization, incarceration, a loss of residential or day placement, or behavior at risk of jeopardizing “placement.”  The terminology about a “jeopardized placement” does not clearly reflect risks to individuals living in family homes, which is not “placement” in the general usage of the term.  The regulations should be amended to clarify that individuals living in family homes with behaviors making those living environments unsafe are eligible. 

The allowable usages of Environmental Modifications are quite narrow, not taking allowing changes needed for safety, including items like keypads on doors to prevent individuals from eloping.  These and other safety-based modifications are critical to allowing many individuals to access their communities and safely live at home.

Individuals who are best served with the Supported Living service are experiencing difficulties in finding a suitable option as they often need a housing voucher for affordability reasons.  However, the regulations mandate Supported Living residences be provider owned/licensed, thus incompatible with housing vouchers.  We would like to see an adjustment made to allow the use of the two options together.

The current regulations only allow customized rates in group day and residential services.  Individuals with comparable needs, but using more integrated services (e.g., employment, in-home private duty nursing) cannot access customized rates and have challenges getting the services they need.  Customized rates should be available for any service that cannot be provided with the base rate due to the exceptional needs of the individual.  At a minimum, this should include all employment and nursing services.

The regulations disallow parents of a minor children from being paid caregivers.  Since residential services are only available to adults, this regulatory hurdle complicates efforts to get children out of nursing homes and Intermediate Care Facilities (ICF) and increases the chances other children will access these institutional settings in the future.  In our personal experience, many of the kids at the Iliff Nursing Home for children are there because the families were well informed about Waivers.  Many of those families have a very low household income and/or limited-English proficiency, making navigating the many complexities of the Waiver infinitely harder.  Allowing these families to be paid to take care of their children at home would open up options for many of those children to be discharged.  The reality of hiring care attendants for people with complex needs is that families will struggle to identify adequate staff and there will be gaps in service.  This makes it impossible for families with all working parents and inflexible jobs to support children with complex needs at home.  This can be remedied if children can have paid parent caregivers.  Justification should be provided demonstrating this need, with automatic eligibility for children in or at risk of nursing home or ICF placement.

Current rules and regulations prohibit lawful current Virginia residents from accessing DD Waiver services while they are living outside of Virginia, as is the case for Foreign Service families, military families, and students with disabilities attending school in another state.  These families have the option to stay on the waiting list while they are out of the area, but do not have the ability to accept services if offered as they do not have the option to choose where they are stationed (and in the case of college students, often do not have the option of attending simply any college or university).  We support an adjustment to the regulations to allow people to use consumer directed personal care services when living outside of Virginia as long as they maintain Virginia residence, while using technology-based options for “face to face visits.”  They would allow Service Facilitators and Support Coordinators to have visits and inspect the home environment.

The BI Waiver does not allow for Personal Care Attendants or crisis support services.  Additionally, many “Tier 1” individuals receive the BI Waiver and are then only eligible for up to 10 weekly hours of Independent Living Services.  These limits can prevent individuals who would otherwise thrive with this Waiver from accepting it.  The use of limited Personal Care hours and crisis support services would make this Waiver a realistic option and increase independent living.

Under the regulations, Assistive Technology vendors cannot add a markup to purchases.  The result is that it became incredibly difficult to find AT vendors, let alone a choice of vendors.  Allowing the 30% mark-up to be reinstated would help in service availability.

The regulations do not allow more than 24 hours of billing overlap for job discovery while someone is accessing a day service.  It can take much more than 24 hours to find the correct job and work with an employer on job prep, such as customized employment.  This minimum should be increased to further remove barriers to employment.

Support Coordination and Service Facilitation

Despite many efforts to move our system to one where people with developmental disabilities and intellectual disabilities are treated equally, there continues to be a divide in relation to Support Coordination.  Prohibiting people from accessing the full range of Support Coordinators because of their IQ does not make sense, nor is it fair or equitable.  We would like to see the regulations for Support Coordination to be identical for all people eligible for the DD Waivers, including the option for privately contracted Support Coordinators.

The eligibility criteria listed to receive Support Coordination and other services for individuals with developmental disabilities states the child must be at least six years old.  Given that the state has adopted the federal definition of developmental disability, which has no age minimum, the regulations should be adjusted to remove any age minimums for service access. 

Under the proposed regulations, Community Service Boards (CSBs) are allowed to operate as service providers, even in cases when families have no choice but to select a CSB Support Coordinator.  There is a clear conflict of interest if the person responsible for helping to evaluate and select service providers is also a provider.  Recognizing that some areas have a dearth of service providers, we suggest a phase out period during which CSBs should step away from the direct provision of DD Waiver services and/or a move that would prohibit CSB Support Coordination if the CSB was also the Service Coordinator.

Early presentations on the redesign stated that a 10 day grace period would be offered for in-person visits, including Support Coordinators and Service Facilitators.  That grace period is critical.  There are times when a family experiences an emergency, weather intervenes, or a Support Coordinator must manage a crisis and a visit must be rescheduled.  The 10 day grace period allows for those visits to be rescheduled without undue stress and burden on individuals and their support team.  The grace period should only be used as needed and should include written justification for its usage. 

Currently, if an individual moves from one CSB to another part of the state and begins to receive Support Coordination from their new CSB, their original Support Coordinator must continue to provide face to face visits until the individual stabilizes.  Given the size of the state, in some cases this means Support Coordinators are spending more than a full day a month driving to do a single visit, sometimes for months on end.  Additionally, for an individual moving a significant distance, a Support Coordination who is based near their old home cannot be available in person for crises and will be without a known network of support providers.  The regulations should be adjusted to allow EITHER an immediate transfer from one Support Coordinator to another when an individual moves more than 100 miles (or equivalent distance in time) OR technology-based visits until such transfer can occur. 

At least one CSB is offering families the option to receive Consumer Directed services without a Service Facilitator, if the family is willing to act in that role without pay.  Regulations should clarify whether or not this is allowed, and in what circumstances.

Miscellaneous

Page 25 of the proposed regulations uses the term “Elder or Disabled with Consumer Direction Waiver” and “Technology Assisted Waiver” instead of using the terminology for the new Commonwealth Coordinated Care Plus Waiver.

Though we understand the rationale behind allowing providers of certain residential services to bill for 344 days per year and receive 365 days worth of funding, it has created significant barriers for providers.  Providers must guess at the beginning of the plan year when vacations or out-of-home time will happen, as it is not consistently planned a full year in advance, so they can balance out planning and billing.  Otherwise, they risk getting to the end of the year and finding they cannot bill for three weeks of the final month of the plan year.  This is a real hardship, especially for Sponsored Residential providers who often serve one individual and receive Waiver reimbursement as their sole source of income.  Instead, allowing providers to go without reimbursement for up to two days per month and recoup that income at the end of the plan year based upon days actually spent out of the home would help level off the income dips and offer some safeguards.  As Waiver prohibits individuals from billing more than a year after a service is received and sometimes denials for insignificant reasons occur, a policy to allow this option with a grace period for the billing would be an appropriate solution.

Closing

The task of redesigning the DD Waivers, writing and editing new regulations, and overseeing our DD service system is massive and daunting.  We are truly grateful for the staff dedicated to working hard to make things run smoothly and ensure people with disabilities can access needed services.  We hope these suggestions are seriously considered and implemented.  We look forward to being part of the collaborative team that continues to improve services for individuals with developmental disabilities in Virginia.

I am writing to say that I strongly support the comments on the waiver made by the Virginia Ability Alliance. As an elderly single parent of a young woman with intellectual disability, I know from experience the real-life difficulties of the issues discussed by the Virginia Ability Alliance. Those of us who live in Virginia desperately need for the state to allocate more resources to the many difficulties and challenges faced by people with intellectual and developmental disabilities and their families. It is a difficult road to travel at the best of times, and many of us have never experienced a viable combination of resources and assistance.

I fully support the Virginia Ability Alliance (VAA) comments and suggestions, and appreciate all you are doing to ensure that all Virginia residents, regardless of ability, get the services and support they need.  As the mother of a teen with Angelman Syndrome, the concerns expressed by VAA mirror my own as I work to safeguard my daughter's future, once I am no longer around or able to care for her myself.  Thank you for your work.  

I fully support and agree with all the comments made by the Virginia Ability Alliance regarding the changes to the Virginia Disability waiver regulations. I am a parent of a child with Angelman Sydrome (age 7) who requires full assistance with all ADLs, cannot speak, is not welcome at a traditional day care, and requires many weekly therapies. The DMAS-62 form is a very cursory form that is I’ll equipped to properly assess a disabled individual’s need for personal attendant care services. Without waiver assistance for my child’s care, we will not be able to continue as a two-person working household, which is absolutely necessary. The personal attendant care hours are essential to ensure we can provide attention and care to our other child, as well. I am deeply afraid of the implications of the Waiver changes on my son’s future when I am no longer able to care for him. I again echo all of the comments made by the Virginia Ability Alliance. Thank you. 

For 12VAC30-50-440 E.3. , The qualifications for support coordinators for individuals with Intellectual disability are inconsistent with qualifications for support coordinators for individuals with a Developmental Disability listed in 12VAC30-50-490. E.6

For 12VAC30-50-490 A., This definition of the "Target group" needs to be clarified, as, by itself it does not exclude individuals with Intellectual Disabilities.  Additionally, if that is indeed the intended definition, are we to then assume that all sections below 12VAC30-50-490 and up to 12VAC30-122 apply only to individuals without a diagnosis of Intellectual Disability?

For 12VAC30-50-490 A.4, Clarification needed on what constitues a special service need.

There are several references to the EDCD and/or Tech Waiver, which no longer exist

Based on review of the regulations, my comments, questions and concerns are listed below.

DD-Waiver Proposed Permanent Regulations

Comments compiled and agreed to by members of the Developmental Disability Waiver Advisory Committee – Heidi Lawyer, VBPD; Tonya Milling & Lucy Cantrell, The Arc of Virginia; GL Pulliam & John Weatherspoon, Sponsored Residential Providers; Karen Tefelski, VaACCSES;  Maureen Hollowell, VaCIL; Jennifer Faison, VACSB and Jennifer Fidura, VNPP.  Each association and/or their individual members will also make comments.

DD-Waiver Proposed Permanent Regulations

Comments compiled and agreed to by members of the Developmental Disability Waiver Advisory Committee – Heidi Lawyer, VBPD; Tonya Milling & Lucy Cantrell, The Arc of Virginia; GL Pulliam & John Weatherspoon, Sponsored Residential Providers; Karen Tefelski, VaACCSES;  Maureen Hollowell, VaCIL; Jennifer Faison, VACSB and Jennifer Fidura, VNPP.  Each association and/or their individual members will also make comments.

Regulatory reliance on “a day” as the sole reimbursement unit in group home and sponsored placement residential settings will be significantly harmful to the fundamental principle of equity, individual served in those settings and small businesses.

1. The proposed regulations establish “a day” as the unit of service for reimbursement for group homes in 12 VAC 30 – 122 – 390 – C1 and for sponsored residential placements in 12 VAC 30 – 122 – 530 – C1, while creating a 24 hour a day service obligation for each service. This provision treats all days across individuals in the services as equal.

2. All residential service days across individuals are not equal. Significant variance will occur based on individual choices and preferences as regards employment and other day support options.

3. Many individuals will choose to avail themselves of day support opportunities which can result in some of them being absent from the home for 7 to 8 hours per day 5 days per week with others choosing programs that entail fewer hours and/or days per week. The Burns and Associates analysis in the Public Comments and Response document dated 4/23/15 – # 44, provided their official guesstimate of 26.1 hours per week in day/work programs for individuals who chose this option (this underestimates the actual time the person is outside the residential setting with these programs as it typically excludes the travel and transition time involved). Even assuming this number is accurate an individual who avails themselves of day support/work will be absent from the home (during prime support hours when they would be awake and active) for 56.55 full 24 hour days per year which represents 169.65 (8 hour shifts) where residential provider does not have to provide staffing nor supports.

4. Some individuals most of whom have prior experience with a range of day/work support options will choose not to avail themselves of day/work support opportunities and will receive plan services in the home on a continuous 24 hour basis. While there are a variety of reasons why an individual may not choose to be out of their home in a structured program during the day (retired, homebody by nature), many of these individuals choose not to avail themselves of outside day/work support opportunities because they have a strong individual preference for the staff and supports they receive in the home. Again, it is important to note that the additional hours they remain in the home are prime support hours where the individual is awake and active and any good residential provider is providing community integration, recreational/leisure, social and other plan supports consistently during these hours to individuals who remain in the home with no difference from the supports they could receive in a day support program. By choosing to allow the residential provider to meet their support needs during the day the individual is able to avoid the regimentation (set travel hours, set lunch times, set activities/schedules etc.) that is necessary and typical in structured day support programs and has much more flexibility in collaboratively achieving the community integration and other support activities they prefer to engage in if they remain in the home.

Clearly, from a residential provider perspective “a day” of support and services for an individual who chooses to be in a day/work support program and an individual who chooses not to is not equal; as the need for staffing, travel and support provision is significantly different.

1. The regulatory requirement that the “day” of these 2 individuals be treated equally for residential reimbursement is significantly harmful to the fundamental principle of equity the regulations seek to establish, individuals who receive residential waiver services and uniquely to small businesses.

2. Gross violations to the principle of equity do occur now at 2 levels:

3. Individuals served in residential programs – the SIS users manual on page 94 clearly establishes that a fundamental principle of equity to be served is that individuals with the same level of need receive the same level of funding; this is reiterated as a purpose for the regulatory changes in the introduction to the changes in the Virginia Register of Regulations 2/4/19 which claims “the same level of spending for individuals with the same level of needs” to provide for “more equitable resource distribution”. Treating the day of individuals who decline structured day/work support programs outside the home as equal to a day for those individuals who do avail themselves of these daytime opportunities creates a clear violation of the intended goal as the individual who avails themselves of daytime opportunities outside the home will receive additional funding for that day when they engage, while the individual who stays home will not receive that additional funding even though they have the exact same level of support needs. Thus, individuals with the exact same level of support needs will receive significantly different daily funding from the state; representing a gross substantial disparity each plan year; merely because they chose to exercise their right to receive their services when, where and from the provider they preferred.

4. Residential providers – treating the day of the 2 different individuals in this circumstance as equal can result in reimbursing 16 hours of awake and active supports and 8 hours of awake and active supports equally when they clearly are not – 16 hours of work should pay more than 8 hours of work; on an annual basis even using the States low guestimate this represents almost 2 months of 24 hour days on inequitably compensated work-an outrage.

5. Individuals receiving residential services are devalued and their rights are being denied at this moment due to the emergency implementation of these changes. The state devalues individuals by telling them that their day (and hence they) are not worth as much if they choose to stay home; literal as well as figurative devaluing. Ironically, the introductory defense of the regulations in the Virginia Registry of Regulations 2/4/19 makes the claim that these changes “provides compliance with the CMS final rule” when in fact they create a perverse direct financial incentive to promote direct violation of their HCBS – CMS final rule rights in areas that range from their free choice of providers/ services and most importantly to their right to have control over their daily schedules. A significant number of providers (based on statements made by them at various multi provider trainings and individual served statements of their experience) directly tell individuals served in their residential programs that they cannot call out or simply choose to stay home from their day/work program, others are less open about the restriction but engage in significant “persuasion” to assure that the individuals do sign up for out of the home programs and go, some may also make acceptance into a program conditional on engaging in a day program outside; I doubt that I am aware of all the ways that some residential providers are restricting an individual’s choice as to their daily routine as regards outside of the home day program but these abuses are occurring now on a daily and routine basis. Several of the examples I am aware of directly used these regulations as the reason they could not/would not have staffing available. The financial incentive to providers to restrict individual choices is magnified when the residential provider is also the provider of the day/work support program as the current structure allows them to “double dip” into the state coffers receiving full reimbursement for the day of residential supports and additional funds for the day of work/day supports; creating an even larger financial incentive. Whether these practices are recognized/deemed important or not by the state – no one can deny given the analysis above that residential providers have a clear and perverse financial incentive to ensure individuals receiving residential services sign up for and leave the home to attend day/work programs. Since the State relies on financial incentives to achieve its other purposes how can they possibly deny that this financial incentive will create this perverse purpose.

6. Very small businesses which focus on providing exceptional residential supports are particularly disadvantaged by equal treatment of unequal days. Large bureaucratic organizations have the economies of scale, physical infrastructure and administrative hierarchy that allows him to engage in “double dipping” and as such are unlikely to protest this provision. However, very small businesses focused exclusively on residential supports have been precluded from “double dipping” by onerous licensing requirements for separate offices, staff and other barriers unless they want to become larger and more bureaucratic organizations; resulting in them shouldering the burden of unequal days with no opportunity to recoup losses. Even if these very small businesses could more easily engage in “double dipping” this would merely mean a proliferation of inbred work/day support programs that would reduce the range of providers and experiences an individual is likely to encounter; thus, reducing the advantage of separate residential and work/day programs promoted by residential only providers.

7. Preemptively, because the State does not provide any opportunity for direct rejoinder to whatever their response is to this criticism, it is important to note the same criticisms were made in 2014 in response to the Burns and Associates rate proposals. As is typical of bureaucratic/ political responses the specific equity, perverse incentives and small business criticisms provided here were not directly addressed in their response, rather they combine these comments with a number of others about per diem’s and set up a specious “straw man” argument they can easily address on reimbursement adequacy by pointing out that the rate structure did provide for 24 hour coverage for everyone in these residential settings and then offering support documentation and staffing flexibility as advantages of their per diem approach. While their response is true it has absolutely nothing to do with criticisms provided here the same inequity is created, the same rights are violated and very small businesses focused solely on exceptional residential supports remain uniquely disadvantaged.

8. Recommendation – the unit of service for residential programs should be bifurcated into 2 units of service each a per diem but with one representing individuals who choose to participate in a work/day support program outside the home and the other representing individuals who choose not to participate in a work/day program outside the home. Individuals who choose not to participate in a program outside the home should receive a higher reimbursement rate that would bring their reimbursement rate in line with the total daily funding of the other individuals who demonstrate the exact same level of need but do participate in outside work/day programs. This approach would retain all of the benefits claimed for the per diem by Burns and Associates while mitigating the harmful impacts. While logistics of working out an exact amount may be difficult due to the variables involved, the State seems to trust Burns and Associates and they are clearly capable given their past work of calculating the averages and variables and arriving at some defensible figure which even if it were not a direct one for one equalization in every individual case would at least mitigate the gross inequities, violation of individual rights and disadvantaging very small businesses that are occurring right now under this current structure.

.

12VAC30-122-10 - #6 & #7 are transposed - Engagement should come before Guide / Guide is 12VAC30-122-330 and Engagement is 12VAC30-122-320

The following definitions are missing 12vac30-122-0: Independent Living & Workplace Assistance as well as the following reserved services: benefits planning, community guide, non-medical transportation, peer support 

12vac30-122-10: "Community Coaching" add "or to support an individual when there is an ongoing barrier to participation" 

QDDP - all references to QDDP should also reference reg 12vac35-105 for clarity and consistency 

Face-to-face Visit  - defiition needs to also explain that face-to-face is the quarterly visit/report done by administation agency for Shared Living 

Supported Living Residential - delete after the word service "taking place in an apartment setting" and change to "taking place in an individual's own home" - this stays consistent as "own home" is also defined and there is not reason to dictate what type of living arrangement a person should live in to receive a service. 

12VAC30-122-80 - C.4. change 30 days to 90 days. It is an unrealistic expectation to have all of the required components competed in 30 days regarding the application/interview/training process and the case management requirements. 90 days is more realistic and supports individuals to have time to make fully informed decisions and not feel pressured or rushed. 

12VAC30-122-90 - C.1.b.(1) - strike - "by the primary caregiver or unpaid provider" - not everyone has a primary caregiver and there is no operational reason to specify that in the regulations. 

12VAC30-122-120 - A.4. change 30 calenday days to 90 calendar days 

A.5. - strike "medically necessary services and supplies" and replace with "services and supports" 

A.6. - strike "supplies" and replace with "supports" 

A.10.3. - strike "such documentation shall be written on the date of service delivery" as this is not consistent with the definition of progress note 

A.13 - change 37.2-600 to 37.2-607 

D. strike "may" and replace with "shall" 

12VAC30-122-210 - A.4.e - change "individuals" to "each individual's needs" - the original language is not person centered 

12VAC30-122-310 - A - after barriers add "or to support an individual's participation when there is an ongoing barrier to participation" 

C.3 - Strike "this service shall not be provided within a group setting". THis is too restrictive and also implies seclusion of the individual owing to the barrier/participation in the service. How is the purpose and intention of Community Coaching supporting indviduals to integrate into community engagement going to be successful if the individual does not experience group settings? Additionally - if the individual's barrier is related to difficulties with group settings the current language will not allow for the service to be facilitated. 

12VAC30-122-390 - E.1.c - strike "at least a daily note" and replace with "a progress note" - to remain consistent with definition and other sections 

12vac30-122-420 - A - add following the words receiving this service "...lives, or is preparing to live, alone..." strike word "typically". As the regulation states that part of the intention of this services is to "secure" independent living it should also apply to those who have not yet secured it. 

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" - as independent living bills once monthly as a single unit of billing the current language is inconsistent with the facilitation of the service. 

12VAC30-122-460 - strike all references to "companion" and replace with "Personal Assistance" 

B.4.E - strike "actitivities" and replace with "activities" 

12VAC30-122-530 - E.1.c - strike "confirming the amount of the individual's time in service and" - as Sponsor Residential no longer bills hourly the current language is not consistent 

E.1.c. - end of second sentence strike "at least a daily note" add "in a progress note" 

12VAC30-122-550 - delete after the word service "taking place in an apartment setting" and change to "taking place in an individual's own home" - this stays consistent as "own home" is also defined and there is not reason to dictate what type of living arrangement a person should live in to receive a service. 

Definitions

Positive Behavior supports - Strike the definition entirely and use the definition from the American association for Positive Behavior Supports

Service Authorizations - delete "medically"

Supported living residential- delete following a service “taking place in an apartment setting”; add following operated by a DBHDS-licensed provider, “taking place in an individual’s own home”

120 - Provider Requirements

A.5.- Strike “medically necessary services and supplies” and add “services and supports”

A.10.d- Strike “medical” in the first sentence

A-10-d  ...Such documentation shall be written on the date of service delivery.

Strike or change to as soon as practicable but no longer than one week after the service.  This is in keeping with the definition of Progress Note from this chapter.

A.10.f- Add “if applicable” within the parenthetical phrase “including specific timeframe”

200 – Supports Intensity Scale® requirements

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 or their SIS tier at time of reaching age of 72, whichever is greater.

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.”

250 – Services covered: Community Living Waiver

Add Family and Caregiver Training

260 – Services covered: Family and Individual Support Waiver

Add Independent Living

530 – Sponsored residential

E.1.c.- Strike “confirming the amount of the individual’s time in service and”

E.1.c.- End of second sentence strike “at least a daily note” add “in a progress note” ·

550 – Therapeutic consultation

B.2.i - Support Dr. Walker’s comments

C.3- Strike “written preparation and telephone communication”

Add new language - see below:

12VAC30-122-80

12VAC30-122-80. Waiver approval process; authorizing and accessing services.

C.6. The providers, in conjunction with the individual and the individual's family/caregiver, as appropriate, and the support coordinator shall develop a plan for supports for each service.

a. Each provider shall submit a copy of his plan for supports to the support coordinator. The plan for supports from each provider shall be incorporated into the ISP. The ISP shall also contain the steps for mitigating any identified risks.

b. The support coordinator shall review and ensure the provider-specific plan for supports meets the established service criteria for the identified needs prior to electronically submitting the plan for supports along with the results of the comprehensive assessment and a recommendation for the final determination of the need for ICF/IID level of care to DMAS or its designee for service authorization. "Comprehensive assessment" means the gathering of relevant social, psychological, medical, and level of care information by the support coordinator that are used as bases for the development of the individual support plan.

c. DMAS or its designee shall, within 10 working days of receiving all supporting documentation, review and approve, suspend for more information, or deny the individual service requests. DMAS or its designee shall communicate electronically to the support coordinator whether the recommended services have been approved and the amounts and types of services authorized or if any services have been denied. If the service request is to be denied for a service that in both type and amount is currently authorized, DMAS or it’s designee shall communicate electronically to the support coordinator that the recommended services have been approved for a period of ninety (90).  In advance of resubmitting the service request, the team shall consider if there are other alternatives and/or provide additional justification for the request.  DMAS or it’s designee shall make a final determination upon receipt of a revised service request and if the service is denied instruct the support coordinator to provide appeal rights to the individual, or family/caregiver as approapriate.

Definitions

Positive Behavior supports - Strike the definition entirely and use the definition from the American Association for Positive Behavior Supports 

Service Authorizations - delete "medically"

Supported living residential- delete following a service “taking place in an apartment setting”; add following operated by a DBHDS-licensed provider, “taking place in an individual’s own home”

120 - Provider Requirements

A.5.- Strike “medically necessary services and supplies” and add “services and supports”

A.10.d- Strike “medical” in the first sentence

A-10-d  ...Such documentation shall be written on the date of service delivery.

Strike or change to as soon as practicable but no longer than one week after the service.  This is in keeping with the definition of Progress Note from this chapter.

A.10.f- Add “if applicable” within the parenthetical phrase “including specific timeframe”

200 – Supports Intensity Scale® requirements 

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 or their SIS tier at time of reaching the age of 72, whichever is greater.

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.”

250 – Services covered: Community Living Waiver 

Add Family and Caregiver Training 

260 – Services covered: Family and Individual Support Waiver 

Add Independent Living 

530 – Sponsored residential 

E.1.c.- Strike “confirming the amount of the individual’s time in service and” 

E.1.c.- End of second sentence strike “at least a daily note” add “in a progress note” · 

550 – Therapeutic consultation

B.2.i - Support Dr. Walker’s comments 

C.3- Strike “written preparation and telephone communication”

.

12VAC 30-122-120 d states progress notes must be completed on the day services are provided. However 12VAC 30-122-20 Definitions "Progress Notes" iii states: is written and signed and dated as soon as practicable but no longer than one week after the referenced service. I believe these sections are in direct conflict. 

The added requirement to finalize progress notes on the day services were provided has the affect of interfering with the primary responsibility of fully supporting the person receiving Medicaid waiver services. This proposed change adds stress to providers

We are a sponsored placement provider. We are a couple that work tirelessly to provide quality services. We do not have additional staff to provide services while someone else sits down to write progress notes, and expend the thought required to adequately capture the day's activities.

We jot down simple notes throughout the day, and in a typical day, we complete the progress notes form at the end of the day. However, there are days when we need to postpone completing the form until the next day.

Type over this text and enter your comments here. You are limited to approximately 3000

Such documentation shall be written on the date of service delivery.

Strike or change to as soon as practicable but no longer than one week after the service.  This is in keeping with the definition of Progress Note from this chapter.

Such documentation shall be written on the date of service delivery.

Strike or change to as soon as practicable but no longer than one week after the service.  This is in keeping with the definition of Progress Note from this chapter.

ositive Behavior supports - Strike the definition entirely and use the definition from the American Association for Positive Behavior Supports 

Service Authorizations - delete "medically"

Supported living residential- delete following a service “taking place in an apartment setting”; add following operated by a DBHDS-licensed provider, “taking place in an individual’s own home”

120 - Provider Requirements

A.5.- Strike “medically necessary services and supplies” and add “services and supports”

A.10.d- Strike “medical” in the first sentence

A-10-d  ...Such documentation shall be written on the date of service delivery.

Strike or change to as soon as practicable but no longer than one week after the service.  This is in keeping with the definition of Progress Note from this chapter.

A.10.f- Add “if applicable” within the parenthetical phrase “including specific timeframe”

200 – Supports Intensity Scale® requirements 

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 or their SIS tier at time of reaching the age of 72, whichever is greater.

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.”

250 – Services covered: Community Living Waiver 

Add Family and Caregiver Training 

260 – Services covered: Family and Individual Support Waiver 

Add Independent Living 

530 – Sponsored residential 

E.1.c.- Strike “confirming the amount of the individual’s time in service and” 

E.1.c.- End of second sentence strike “at least a daily note” add “in a progress note” · 

550 – Therapeutic consultation

B.2.i - Support Dr. Walker’s comments 

C.3- Strike “written preparation and telephone communication”

.

Such documentation shall be written on the date of service delivery.

Strike or change to as soon as practicable but no longer than one week after the service.  This is in keeping with the definition of Progress Note from this cha

I am the parent of a 20 year old with autism who is currently receiving waiver services in Fairfax County, and I support the comments submitted 3/7/19 by the Virginia Ability Alliance.  Thank you.  

I am the parent of a young woman who is priority one on the wait list.  I support the comments of the Virginia Ability Alliance and emphasize the need for Virginia to change any language that assumes a wait list forever.  We are a better people than that.

As a parent of a 19 year old special needs child, I appreciate the redesigned waiver, however, the waitlist for the DD waiver is incredibly discouraging.  The timelines suggested only rise hopes that lead to disappointment.

I agree fully with the comments of the Virginia Ability Alliance.  

Thank you for working hard for our special kids and their families.  

Sincerely, Lynne Smith

12VAC30-50-490. E.6 
There is no mention of requiring a degree to provide services.  If a degree is required, propose that degree "in human services" be expanded to meet QMHP eligible as defined by the Virginia Board of Counseling (meaning a degree in an unrelated field is acceptable provided there are sufficient human services credits). 

12VAC30-50-440 A. States target group is individuals with Intellectual Disability; however, there is no definition of Intellectual Disability noted in the Regs

12VAC30-50-440 D. Definition of Services Inconsistent with 12VAC30-490D.  Why are they different?

12VAC30-50-440 E.3.  Qualifications for support coordinators for individuals with Intellectual disability are inconsistent with qualifications for support coordinators for individuals with a Developmental Disability listed in

12VAC30-50-440 E.3.b.2, 6 Clarification regarding what the expectation is for #2 Negotiating with individuals and service providers & #6 Coordinating the provision of services by diverse public & private providers. 

12VAC30-50-490 A. This definition of the "Target group" needs to be clarified, as, by itself it does not exclude individuals with Intellectual Disabilities.  Additionally, if that is indeed the intended definition, are we to then assume that all sections below 12VAC30-50-490 and up to 12VAC30-122 apply only to individuals without a diagnosis of Intellectual Disability?

Based on the definition, those under the age of 6 are excluded, does this mean those with DD under six cannot receive Waiver/be on Waitlist? 

12VAC30-50-490 A.1 Indicates a Face-to-Face every 3 months; however, 12VAC30-440A.1. indicate Face-to-Face every 90 days.  These need use same time frame/language for defining timeframe.

12VAC30-50-490 A.2 This section states that individuals will be placed on a waiting list.  If the intention is that section 12VAC30-50-490 applies only to Non-ID individuals, then these regulations provide no guidance that individuals with ID can be placed on the waiting list, as there is no corresponding text in 12CAC30-50-440

12VAC30-50-490 A.4 Clarification needing regarding what constitutes a special service need.

12VAC30-50-490 C.  States CSBs/BHAs SHALL contract with private support coordinators/case managers.  This needs to be changed to MAY contract with private support coordinators/case managers; change to match language in 12VAC30-50-490 E.1. and 12VAC30-50-490 F. 1

12VAC30-50-490 D. Definition of Services Inconsistent with 12VAC30-440D. 

12VAC30-50-490 E. 2 and 3 These sections list restrictions on who can provide support coordination, restrictions that do not appear under the qualification in section 12VAC30-50-440.  Are we to assume these restrictions apply only to support coordinators providing services to individuals without an Intellectual Disability?

What is meant by otherwise related by business or organization to the direct care staff person in  E. 2 iii?  This seems very broad and concerning with all DD support coordination being under the CSB.  Does this mean if a person has a child needing Waiver services, the person will have to quite their job or refuse to get individual services at the CSB.

12VAC30-50-490 E.5 This section states that an individual providing support coordination needs to have a degree in human services.  As this requirement is listed only under 12VAC30-50-490, and not under 12VAC30-50-440, are we to assume this is a requirement only for individuals providing support coordination for clients without an ID diagnosis?  Propose that degree "in human services" be expanded to meet QMHP eligible as defined by the Virginia Board of Counseling (meaning a degree in an unrelated field is acceptable provided there are sufficient human services credits).

12VAC30-50-490 E.6 Qualifications for support coordinators for individuals with Intellectual disability are inconsistent with qualifications for support coordinators for individuals with a Developmental Disability listed in 12VAC30-50-440. E.3  

12VAC30-50-490 E.7 a-f This section describes supervisory requirement, and there is no corresponding text in 12VAC30-50-440.  Are we to assume these supervisory requirements apply only to support coordinators providing services to clients without an ID diagnosis?

 For E.7. a: please define Human Service Degree.   If a degree is required, propose that degree "in human services" be expanded to meet QMHP eligible as defined by the Virginia Board of Counseling (meaning a degree in an unrelated field is acceptable provided there are sufficient human services credits).

12VAC30-50-490 E.8 There is no corresponding section in 12VAC30-50-440 requiring one hour of documented supervision every 3 months.  Are we to assume this requirement applies only to support coordinators providing services to clients without an ID diagnosis?

12VAC30-50-490 E.9 There is no corresponding section in 12 VAC30-50-440 requiring support coordinators to receive 8 hours of training annually.  Are we to assume this requirement applies only to support coordinators providing services to clients without an ID diagnosis? Recommend removing.

12VAC-30-122-20 Defines "Support Coordinator" as the person who provides support coordination services to an individual in accordance with 12VAC30-50-455. Section 12VAC30-50-455 is repealed.

"Immediate family member" definition references (12 VAC 30-50-455 ), which is no longer in effect


12VAC-30-122-30 B References the Elderly and Disabled Waiver and the Technology Assisted waiver, neither of which exist.  

12VAC30-122-50 A.2 What is needed to document needing level of care on the annual basis?

12VAC30-122-70 Recent audits by DBHDS have wanted to see that individuals put on the Waitlist agreed to receipt of services within 30 days if awarded the slot.  Is this a requirement?  If so, where is this to be documented?

12VAC30-122-70 H. Should reference DBHDS responsibility for collecting the forms and sending to CSBs/BHAs.

12VAC30-122-80 C.5.b. Retain slot used to be 180 days now 120 days; Suggest this changes back to 180 days.

12VAC30-122-80 C.6.a The statement "The plan for supports shall also contain the steps for mitigating any identified risks" is a concern.   There are times individuals do not want to take steps to mitigate risks.  They have the right to refuse, with choice and dignity of risk.  This statement should be revised to indicate "The plan for supports shall also contain the steps for mitigating any identified risks or document the person's refusal of mitigating actions."

12VAC30-122-90 E.3 Clarification that regional WSAC is for BI only (not for other Waivers) and clarification on why indicates regional WSAC? 

12VAC30-122-90 G.2.a Emergency Slot Clarification on number of emergency slots, what is 10% based upon?

12VAC30-122-100 D. An amendment is needed for statement "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."  This statement must include caveat as permitted by confidentiality regulations including HIPAA, 42 CFR and Human Rights.

12VAC30-122-40 B States individuals with DD who are inpatient may receive Support Coordination as described in 12VAC30-50-440.  That section referred to only applies to individuals with ID.

12VAC30-122-70.H Does the DBHDS process of sending letters meet this requirement of annual contact?

12VAC30-122-120 A. 10.e.1 Concern with implications of Standardized or Formulaic notes being considered unacceptable.  Clarification that templates are acceptable to ensure notes contain appropriate information.

 
12-VAC30-122-120 A. 10.g.3 Concern regarding matching language of support plan needs with licensing regulations

Clarification regarding services rendered schedule and timetable

12-VAC30-122-120 A. 14 Why do you report APS issues to DARS?  This is a potential HIPAA concern.

12-VAC30-122-120 A. 16 Is requirement that providers "must read and write in English" related to literacy or meant to mean must read and write in English?

12-VAC30-122-120 B Clarification on where the objective documentation must be maintained.  Is this in the provider record and/or Support Coordination record?

12-VAC30-122-150 A. 2.e Concern regarding ensuring Conflict Free Case Management with statement "The individual's support coordinator/case manager may also function as the service facilitator."  Suggest adding, if the support coordination/case manager agency has a provider agreement with DMAS to provide such service.

12VAC30-122-180 E. 4 The regulations state that new hires have to complete competencies in 180 days.  Is this the same requirement for supporting individual with a Leve 6 or 7?    

12-VAC30-122-190 A.6 Support Coordinators shall conduct and document a minimum of quarterly visits to all other individuals at least one annually occurring in the home.   It used to be that we alternate visits occurring in the home.

Also asking for consistency between 90 day visit, 3 month visit and quarterly visit
122VAC30-122.190.C.2.c This states a Medical Exam for children up to age 21 shall be completed according to frequency recommended by EPSDT.  Whose responsibility is it to ensure these are completed (service provider, SC, parent?)

12-VAC30-122-200 A.1 Indicates SIS stops at age 72.  How are those older than 72 assessed for intensive support needs to ensure ability of providers to continue to serve individuals?

12VAC30-122.200.A.2.b Clarification is needed about who completes the Brigance Inventory, Vineland, or COACH.

Clarification is needed regarding if the Brigance Inventory, Vineland, or COACH is needed every two years for those 5-15 without tiered services.

Clarification is needed regarding how often a SIS must be completed for individuals 5-15 years who do not receiving tiered services.

12VAC30-122-210 C.3  Inconsistent with 12VAC122-360 For Electronic Home based services, 12VAC30-122-210 C.3 indicates is the $5000 limit per calendar year while 12VAC30-122-360 C. 1. indicates limit is $5000 per ISP plan year?

12 VAC30-122-270 B.2.a Service Requirements states done in least expensive, cost effective manner.  Who determines least expensive cost effective manner?

12 VAC30-122-270 D.5 Clarification needed if the "start date of the authorization" means date authorized?

12VAC30-122-290 E.2 Reference to 12VAC35-105 seems to miss part of the licensing regulation reference.
12VAC30-122-310 E.2 Reference to 12VAC35-105 seems to miss part of the licensing regulation reference.
12VAC30-122-320 E.2 Reference to 12VAC35-105 seems to miss part of the licensing regulation reference.

12VAC30-122-340 C.8 Concern that a non-sponsor family member living in the same home cannot provide CD services.  There may be limited circumstances where this may be the only option.  Recommend this must be done with Objective Documentation this is the option.

12VAC30-122-340 C.9 Concern that a family member cannot provide CD services.  There may be limited circumstances where this may be the only option.  Recommend this must be done with Objective Documentation this is the option.

12VAC30-122-350 E.2 Reference to 12VAC35-105 seems to miss part of the licensing regulation reference.

12VAC30-122-360 C.1 Inconsistent with 12VAC122-210 For Electronic Home based services, 12VAC30-122-210 C.3 indicates is the $5000 limit per calendar year while 12VAC30-122-360 C. 1. indicates limit is $5000 per ISP plan year?

12VAC30-122-370 B.1. b Clarification if possible to receive Environmental modification on multiple vehicles (i.e. one at the residence and possible another that an person uses to give the individual a ride to appointments).

12VAC30-122-380 D.5 Reference to 12VAC35-105 seems to miss part of the licensing regulation reference.
12VAC30-122-390 D.5 Reference to 12VAC35-105 seems to miss part of the licensing regulation reference.
12VAC30-122-410 D.4 Reference to 12VAC35-105 seems to miss part of the licensing regulation reference.
12VAC30-122-420 D.5 Reference to 12VAC35-105 seems to miss part of the licensing regulation reference.
12VAC30-122-460 D.4.b Reference to 12VAC35-105 seems to miss part of the licensing regulation reference.
12VAC30-122-490 D.4.b Reference to 12VAC35-105 seems to miss part of the licensing regulation reference.
12VAC30-122-530 D.5 Reference to 12VAC35-105 seems to miss part of the licensing regulation reference.

12VAC30-122-540 A. Clarification on what constitutes "an apartment setting". Could this be a townhome or house with private entrances for multiple individuals? 

12VAC30-122-540 D.4 Reference to 12VAC35-105 seems to miss part of the licensing regulation reference.

To Whom It May Concern,

I am writing to support the comment letter sent to you by the Virginia Abilities Alliance.  As the parent of a young adult with an intellectual disability I am concerned about long waiting lists for services, as will as the lack of waiver funding.  My husband and I are in our late fifties and are very concerned that our daughter will not receive an appropriate housing placement until after our deaths.  As pointed out in the letter, that outcome would be extremely stressful for our daughter.  Our desire is to see her placed in a supportive living environment while we are stil able to assist with the transition and help her to achieve her optium level of independence and functioning.  I believe that is every parents wish.

Thank you,

Barbara Mack

 Section 20: Definitions

• Challenging Behavior – in the last sentence, after “may include” add "but not be limited to". There are many other types of behaviors that place individuals and others at risk.
• Family - remove Legal Guardian from list and have a separate and distinct definition for said, including legal guardian’s role, responsibilities and limitations as it relates to these regulations.
• Positive Behavior Supports - use A.A.P.B.S. definition
• Progress Note - use of this definition should be consistent throughout entirety of the regulations.
• Supported living residential – remove “in an apartment setting” and replace with “in the individual’s home”
• Add a definition for Independent Living

Section 60: Financial eligibility standards

• B3a1 and B3b1 - Remove “for an individual employed at least eight” hours.

Section 80: Waiver approval process

• C4 - Extend timeframe for initiating service from 30 days to 60 or 90 days. It takes more than a few weeks to provide and obtain completed service applications (and related materials), arrange for tours, schedule and conduct intake meetings and hire/train/assign staff, etc.

Section 90: Waiting List

• C1a – Add (reinstitute) age (65 or 70) of primary care giver as criteria for Priority One eligibility in an effort to allow for a modicum of individual and family service planning before the individual is in crisis, dealing with the death or serious health issue of a aging parent and potential life-changing move to an unfamiliar setting.
• E3 – All waiver slots should be for Priority One individuals. Further, if there is a lack of interest in the BI waiver, the slots should be reassigned to Priority One CL and FIS waivers with no need for WSAC session to review re-assignment to Priority Two and Three.

Section 120: Provider requirements

• A4 – Extend timeframe for initiating service from 30 days to 60 or 90 days (see note in section 80 above)
• A6 – Remove “supplies” and replace with “supports”

Section 190: Individual Support Plan

• A8 – Specify that the ISP is to be provided by the Support Coordinator

Section 200: Supports Intensity Scale

• A1 – Clarify what assessment and rate reimbursement determinant structure is to be used for individuals older than 72.
• A2a – Remove “three” and replace with “four” years for consistency with the state waiver application to CMS.
• A2d – Remove “six” months and replace with “two” months. Providers regularly support individuals following surgeries and other medical events/conditions wherein it is immediately known and/or highly predictable that the individual’s supports needs have, or will have, changed significantly for an extended time period but also likely to last less than six months before returning to baseline.
• A4 -   Remove scoring protocols from regulations and communicate to providers via some other means.

Section 390: Group Home residential

• E1C – Change “daily note” to “progress note”

I support the comments submitted by the Virginia Ability Alliance.  In particular, I ask that you allow for a spend down  for people with DD waivers  
People with the DD Waivers do not have the option to “spend down” income over the Waiver income cap on medical expenses to demonstrate eligibility for Waiver. The net result is that people with either
high earned or unearned income are ineligible for the DD Waivers, though they are eligible for the CCC Plus Waiver that does have a “spend down” option. As we see the generation of baby boomers retiring and SSDI payments to adult children reaching and exceeding the limits of financial eligibility for Waiver, it would be wise to amend the DD Waiver Regulations to allow a “spend down” option similar to that allowed under the CCC Plus Waiver. Additionally, regulations should protect eligibility for anyone who is put over the monthly income cap as a result of SSDI received from parents. This benefit cannot be refused or reduced, despite the wishes of the person with a disability, yet it can have the effect of making them ineligible for crucial services they cannot afford to fund with their own incomes.
 

Our 48 year-old son has been on the Developmental Disability waiver wait list for well over 20 years (and still waiting).  We strongly endorse the comments of the Virginia Ability Alliance regarding the  current waiver process.  We have seen some improvement over the years, but not nearly enough to address the needs of many individuals throughout the Commonwealth. We are seriously nearing the point of our son being left with no support system as we age beyond the ability to continue meeting all of his needs!!  We, too, are becoming incapacitated with age-related medical issues that require a lot of our time and energy. Please, please take the comments and recommendations seriously - lives depend upon it!!.

Thank you for the difficult and complex that it takes to improve the system

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...Such documentation shall be written on the date of service delivery.

Strike or change to as soon as practicable but no longer than one week after the service.  This is in keeping with the definition of Progress Note from this chapter.

...Such documentation shall be written on the date of service delivery.

Strike or change to as soon as practicable but no longer than one week after the service.  This is in keeping with the definition of Progress Note from this chapter.

Strike or change to as soon as practicable but no longer than one week after the service.  This is in keeping with the definition of Progress Note from this chapter.

1.I support the comments made by Virginia Ability Aliance.

 I support comments by  Virginia Ability Alliance.  Please do not decrease the CCC+ waiver hours.

1.    I support the comments made by Virginia Ability Alliance.
2.    To support the families in caring for their children while they are on the waiting list, do not continue to decrease CCC Plus Waiver hours. 

I support  comments made by the Virginia  Ability Alliance.

Don’t reduce the CCC plus Waiver time.