I provide the following 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.  This recommendation is one of the most important ones in this list. 

• Support the allowance of employment services organizations (ESOs) to be providers of Peer Mentor Supports, Employment & Community Transportation Services and Community Guide services.

• Support the consistent use of “progress notes” as defined in the DD Waiver regulations versus • the use of “daily note” references. We support the definition of “progress notes” as defined in 12VAC30-122-20 “Definitions” for consistency. “Progress notes” means individual-specific written documentation that (i) contains unique differences specific to the individual’s circumstances and the supports provided, and the individual’s responses to such supports; (ii) is signed and dated by the person who rendered the supports; and (iii) is written and signed and dated as soon as is practicable but no longer than one week after the referenced service.”

• Support changing the 10-day requirement to a 15-day requirement for service providers to submit quarterly reports

. • Semi-Annual Supervisory Notes for DSPs including “individual’s satisfaction with service provision”. Requirement should be eliminated or changed per comments below: o Community Coaching (122-310.E.2), Community Engagement (122-320.E.2), Group Day (122-380.D.5.), Group Residential (122-390.D.5), Crisis Support Services (122-350.E.2) and Center-Based Crisis Support Services (122-300.E.2) all have additional burdensome requirements under Service Documentation or Provider requirements that state that there must be written supervision notes for each DSP, signed by the supervisor and included semi-annual documentation of individual’s satisfaction by the supervisor. (Center-based Crisis Supports does not include the semi-annual requirement.) Semi-Annual supervisory documentation of an individual’s “Satisfaction with service provision” or “observation of satisfaction” is also required. ? This is duplicative of the initial and annual thereafter required documentation of proficiency of staff competencies included under 122-180. Not to mention, much more stringent. ? 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.

• Recommend that DMAS and DBHDS actively work with CMS to develop and seek approval of a checklist to substitute for “progress notes” (narrative daily notes) - the demands of which detract from providers’ resources to effectively support individuals. • 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.