Sorry for the mulitple entries without documentation - I have finally found a web browser that allows for comments to be added...

Comments:

Chap. II Page 9:

CMHRS Providers must report any knowledge of adverse outcomes for an individual currently receiving services or who have been discharged from services within 180 days of the incident.

Comment: It is not within the means of a provider to continue to be aware of or track adverse events of consumers once they have been discharged from services . This requirement puts an unjust burden on the provider and will likely be a requirement that the provider will always be out of compliance. It would make better sense to have this be an expectation of the Care Coordination activities of the Health Plans.

Chap II Page 13:

a. Effective January 1, 2019, DMAS and its contractors will deny reimbursement from services rendered by a QMHP and QMHP-Trainee staff who are not registered with the Board of Counselors

Comment:  This continues to be a subject that Agencies/Providers will feel the burden of having a hired staff who potentially cannot  bring in revenue for at least 1 mo’s time from hire while the registration process is taking place through the Board of Counselors. I would ask that DMAS and the Board of Counselor’s look at a compromise to this requirement. Positions that employ QMHPs tend to have a higher rate of turnover which could have a direct effect on the provision of care to the individuals served if there is a minimum of a 1 month time frame before new staff who meet the qualifications for QMHP and QMHP –Trainee can be used to provide the service.

Chap IV Page 9: Definition:

???????Medication Management” means counseling on the role of prescription medications and their effects including side effects; the importance of compliance and adherence; and monitoring the use and effects of medications. Assistance with medication management is only available to parents and guardians when it is for the direct benefit of the individual and the individual is present.

 Comment :In Chapter IV, this activity is relegated to LMHP and LMHP-Types only.  I understand that “counseling” falls within the scope of the LMHP/Type licenses and education, but I am puzzled by definition including the information on medication use and side effects as also falling within the scope of practice for an LMHP and LMHP-Type. An employee who is a registered nurse and may also be QMHP would seem to have better knowledge of medications and their side effects and would also fall within the scope of their license.  A large component of our QMHP’s and even our case managers at times is to provide education on medications, their potential side effects and monitoring of medication adherence in the community and  working closely with the Prescriber on these types of issues and activities.

Chap IV Page 18 :

When the initial comprehensive needs assessment recommends several services for an individual, one assessment will be allowed for all services provided within the same agency. An agency means the same as the DBHDS provider definition located in 12VAC35-105-20. If additional services are required after the completion of the initial comprehensive needs assessment, the provider may amend the initial comprehensive needs assessment or conduct a new comprehensive needs assessment.

Comment: The regulations do not address or clearly state if an agency who provides multiple CMHRS services can complete and use just one Comprehensive Needs Assessment  (CNS) annually after the initial one has been completed…(with amendments as needs and services change.) If this is the intent of the regualtions– then this should be more clearly stated within the regulations.

Chap IV  pages 18 and 20:             

Case Management assessments require different staff credentials than the staff credentials for direct MH services. Refer to Chapter II of this manual for additional information. MH Case Management assessments must be provided in accordance with the provider requirements defined in DBHDS licensing rules for case management services.

Comment: The CM Assessment is clearly stated on page 18 and is described as different that the CNA , however on page 20 the regs state … The comprehensive needs assessment must be completed annually for all services or when there is a need based on the medical, psychiatric or behavioral status of the individual.

Based on the copied statement above, it appears the Comprehensive Needs Assessment is required by all services including case management… Also,  If an agency provides CM as well as other services, Can the Comprehensive Needs Assessment be utilized by the CM service as their assessment? I think the regulations would be clearer if the Case Management Service had its own section rather than weaving it in and out the fabric of all services being addressed in Chapter IV.

Chap IV Page 22:

All ISPs shall be completed, signed and contemporaneously dated by the LMHP, LMHP-Types, QMHP A/C/& Es.  In addition, there are similar regulations addressing TX Plan reviews on the same page.

Comment: MH CM do not always meet the qualifications for these credentials, nor are they required for this service. Clearer regulations are needed for the expectations for ISPs for case management services.

Chap IV: Psychosocial  Rehabilitation regulation (starting on page 51)

Comment: The term Restorative Facilitation is used several times throughout the manual– Can you clearly define the term.

Chap IV: Crisis Intervention, page 57:

Clarification requested: CI may be provided in settings other than the outpatient clinic if “clinically/programmatically appropriate based on the needs identified in the comprehensive needs assessment.”  For crisis intervention, will the prescreening if done to determine need for inpatient treatment meet the definition for “comprehensive needs assessment”?

Chap IV : Crisis Stabilization, Page 61

Service Requirements:

Psychiatric evaluation including medication evaluation provided by a licensed psychiatrist and including pharmaceutical assessment and treatment or prescription medication intervention and ongoing care to prevent future crises of a psychiatric nature.

Comment: A full Psychiatric Evaluation is not always warranted, particularly if the individual is already being treated by the provider’s prescriber . What is needed is the 24/7 support, counseling and structured environment to avert further decompensation and hospitalization. I would ask that this be on a as deemed necessary basis.

A Psych eval by a Psychiatrist puts an increased burden on the lack of available resources for Psychiatrists for Medicaid covered services.  Nurse Practitioners should be considered to meet the qualification and credential level to provide the Evaluation and medication services. This would be in line with the current health care trends . Even the recent regulation changes for Nurse Practitioners supports this trend.

page 64 - The provision of this service to an individual shall be registered with DMAS or its contractor within one calendar day of the completion of the comprehensive needs assessment. 

Comment : The CCC+ MCOs allow for 48 hours– Could this match the CCC+ Plan’s requirement for consistency.

Chap IV: MHSS,Page 72

TGH, mental health supervised living and assisted living facility providers shall not serve as the MHSS provider for individuals residing in the providers’ respective facility. Individuals residing in facilities may, however receive MHSS from another MHSS agency not affiliated with the owner of the facility in which they reside.

Comment: DBHDS licensed MH Supervised Residential Programs are not a billable CMHRS to Medicaid ; so I wonder what the rationale is to not allowing the same provider to provide MHSS services within the MH Supervised Residential Program.

Chap IV : MHCM, Page 75:

A comprehensive needs assessment must be completed by a qualified mental health case manager to determine the need for services. The CM comprehensive needs assessment is part of the first month of CM service and requires no service authorization.

Comments:  Earlier in the chapter the following is documented: Case Management assessments require different staff credentials than the staff credentials for direct MH services. Refer to Chapter II of this manual for additional information. MH Case Management assessments must be provided in accordance with the provider requirements defined in DBHDS licensing rules for case management services. And earlier in the chapter it also states that an LMHP or LMHP-Type must complete a Comprehensive Needs Assessment (CNA)– there is conflicting information in the regulations regarding the CNA and Case Management requirements for assessments.- Please address and clarify.

 Page 78:Request clarification to the following statement:

Making collateral contacts, which are non-therapy contacts, with significant others to promote implementation of the service plan and community adjustment.

Comment: Case Managers are often checking in with all providers of the client’s , even a  therapist, if needed,  to determine continued needs and progress of the individuals receiving case management service.