Comment 23
Appendix C: Participant Services, C-1/C-3: Provider Specifications for Service, Consumer-Directed Attendant Care, Other Standard, narrative, 5th paragraph, page 79
The draft Application states that the consumer-directed assistant will not be compensated after receipt of a records check or Child Protective Services (CPS) Central Registry that resulted in identification of a barrier crime. The cessation of wages/compensation should occur only after appropriate notice has been provided to the employer of record. The employer of record will not be notified by the reporting agency; rather the employer of record must depend on the fiscal agent to inform them of any barrier crimes or CSP findings. The employer of record should have the opportunity to know about any prohibition of employment resulting from these record checks before ending compensation to the assistant. Adequate notice to the employer of record would provide the employer time to take any immediate, necessary action to protect the individual receiving services from negative action by an assistant whose wages/compensation has been ended by the fiscal agent. The working relationship between the individual, employer of record and the assistant can involve access to the individual’s home and personal belongings. It may be prudent that the employer of record be provided an opportunity to be aware that wages/compensation are ending so that they do not unknowingly continue to allow access to the individual’s home or schedule work hour for the assistant.
RECOMMENDATION: When employment of an assistant must occur due to a barrier crime, it should be done so in a manner that protects the safety of the individual. The notice from the fiscal agent to the employer of record should be made confidentially, in a timely manner to allow time for the employer of record to take any prudent action, and in a manner that assures the fiscal agent’s notice has reached the employer of record before the fiscal agent takes action to end wages/compensation.
Comment 24
Appendix C: Participant Services, C-1/C-3: Service Specification, Respite, Service Definition, narrative, 4th paragraph, page 81
The draft Application states that individuals who elect to use consumer-directed services may choose a services facilitator to provide training and guidance. When individual elects to use consumer-directed services, but does not choose a services facilitator for training and guidance, services facilitation is not required.
RECOMMENDATION: Include the process for the individual to initiate and continue consumer-directed services in the absence of services facilitation. This process should include a description of the role of the employer of record and role of the case manager/support coordinator.
Comment 25
Appendix C: Participant Services, C-1/C-3: Service Specification, Respite, limits on the amount, frequency, or duration of this service, narrative, 4th paragraph, page 81
The draft Application states that an individual who receives personal care from a legally responsible individual (LRI) would not be eligible for respite. This appears to assume that the LRI is the only caregiver and that the individual does not have an unpaid caregiver. There are circumstances in which the LRI is not the primary caregiver.
RECOMMENDATION: Add language to clarify that if the individual has an unpaid primary caregiver such as a second parent, friend or other family member, the individual may qualify for respite services based on the support they receive from an unpaid caregiver.
Comment 26
Appendix C: Participant Services, C-1/C-3: Service Specification, Respite, Specify whether the services may be provided by, page 82
Individuals may have a legal guardian who is not the individual’s unpaid primary caregiver or paid caregiver.
RECOMMENDATION: Permit legal guardians of adults with DD to be respite staff, if the legal guardian is not the unpaid primary caregiver nor a paid caregiver.
Comment 27
Appendix C, Participant Services, C-1/C-3: Provider Specifications for Service, Provider Category, page 82
Provider categories can be “Individual” or “Agency”. These categories are not listed in a consistent format/order throughout the draft Application.
RECOMMENDATION: For those services that are offered through both the individual and agency categories, the Application should consistently list individual or agency first in each service section under this “Provider Category” item.
Comment 28
Appendix C: Participant Services, C-1/C-3: Provider Specifications for Service, Consumer-Directed Respite Care Assistant, Other Standard, narrative, 4th paragraph, page 83
Same as comment #23 above.
RECOMMENDATION: Same as recommendation for comment #23 above.
Comment 29
Appendix C: Participant Services, C-1/C-3: Service Specification, Services Facilitation, limits on the amount, frequency, or duration of this service, narrative, 4th paragraph, page 87
Depending on the service and specific program requirements, the frequency of services facilitation visits should be determined based on the needs of the individual as determined through a discussion between the individual and services facilitation organization.
RECOMMENDATION: Clarify requirements for the frequency of visits.
Comment 30
Appendix C: Participant Services, C-1/C-3: Provider Specifications for Service, Services Facilitation Provider, Other Standard, narrative, 4th paragraph, page 88
Service facilitation provided by a case manager, if this is the choice of the individual, avoids multiple visits to an individual’s home by different providers. This practice has been allowed since 2000 and is preferred by the majority of individuals, where the option is still available. Since 2017, changes to how individuals access and receive private case management, the availability of private case management has decreased dramatically. Hence, the choice of individuals to receive services facilitation from their private case management provider is an issue for a very small number of individuals who are afforded the choice of private case management. Nonetheless, it remains a valuable option for the small number of individuals who have choice of case management providers.
RECOMMENDATION: Maintain the current practice of allowing individuals to choose to receive their services facilitation from their DD case manager.
Comment 31
Appendix C: Participant Services, C-1/C-3: Service Specification, Assistive Technology, Service Definition, narrative, 2nd paragraph, page 90
Needed assistive technology has been denied by DBHDS based on a narrow definition of assistive technology. DBHDS has justified their denials of requested assistive technology by stating the needed items are not medically necessary. The definition in the draft Application requiring that the assistive technology is needed “for remedial or direct medical benefit” will perpetuate these narrow and harmful determinations.
RECOMMENDATION: Expand the definition to include the clearer assistive technology core service definition on page 177 of the Centers for Medicare and Medicaid Services (CMS), “Instructions, Technical Guide and Review Criteria” for 1915(c) waivers. The CMS definition focuses on functional capabilities, not only medical needs. Medical benefit should remain a part of the FIS Waiver assistive technology definition as well.
Comment 32
Appendix C: Participant Services, C-1/C-3: Service Specification, Companion, limits on the amount, frequency or duration of this service, narrative, 2nd paragraph, page 115
Companion services provide informal support that are vital to individuals who may not want or need ongoing skill development. Limiting companion services to eight hours a day restricts the natural daily flow of life and may not be adequate for the needs of an individual, especially if they are not using significant daily hours of residential services. The limitation results in individuals missing opportunities to participate in integrated social group activities with people who are not disabled and to enjoy activities that may last for more than eight hours without interruption due to the change in shifts from companion to another service type. The limitation of eight hours a day can result in the provision of more expensive services, from a different staff, to provide socialization and other support that could have otherwise been provided by companion services. The determination of companion hours should be based on the individual’s needs and preferences.
RECOMMENDATION: Increase the allowable amount of companion hours to 16 hours per day.
Comment 33
Appendix C: Participant Services, C-1/C-3: Service Specification, Employment and Community Transportation, Service Definition, narrative, page 126
Activities of the Employment and Community Transportation agency are primarily administrative.
RECOMMENDATION: Permit required administering agency activities to be provided via telehealth.
Comment 34
Appendix C: Participant Services, C-1/C-3: Service Specification, Employment and Community Transportation, Service Definition, page 126
The draft Application requires verification that the individual “does not have sufficient personal funds financial resources” to pay for the transportation themselves. Other Medicaid services do not require such verification of ability to pay. Requiring this verification is not time well spent by providers, especially considering the rate structure for administering agencies. The requirement is not consistent with the provision of other FIS Waiver services.
RECOMMENDATION: Remove requirements for verification of the ability for the individual to pay for transportation.
Comment 35
Appendix C: Participant Services, C-1/C-3: Provider Specifications for Service, Employment and Community Transportation, Provider Qualifications, page 127
Centers for Independent Living are not licensed by DBHDS. Centers for Independent Living incorporated in the Commonwealth of Virginia must meet the requirements in Virginia Code, § 51.5-161.
RECOMMENDATION: Modify the Provider Qualifications item by listing Centers for Independent Living in the Other Standard block, not in the License block.
Comment 36
Appendix C: Participant Services, C-1/C-3: Service Specification, Environmental Modifications, Service Definition, narrative, page 130
Individuals who are trying to transition from nursing facilities and other institutions may need the residence they previously lived in or a new residence to be accessible before they can transition. Experiences have included people leaving the institution by stretcher, the transportation company lifting the individual up home stairs, and then the individual having no way to leave their home, if a needed ramp was not installed prior to their transition home. This could be the situation if the individual did not use a wheelchair before going into the institutional setting or if they leave an institutional setting to a home different from where they lived before their institutionalization. CMS allows the needed environmental modification to be authorized and begun while the individual is still in the institution. This allowance is described on page 174 of the CMS, “Instructions, Technical Guide and Review Criteria” (Technical Guide) for 1915(c) waivers.
RECOMMENDATION: Allow authorization of environmental modifications needed for transition from an institutional setting up to 180 days in advance of transition from an institutional setting.
Comment 37
Appendix C: Participant Services, C-1/C-3: Service Specification, Environmental Modifications, Service Definition, narrative, page 130
Environmental modifications needed to repair an existing accessibility feature are sometimes denied if Medicaid did not initially fund the item needing repair. For example, if an individual had a lift installed on a van with the individual’s funds and subsequently the lift needs repair outside of warranty or routine maintenance, the repair or maintenance is denied due to the lift being purchased by the individual instead of with Medicaid funds. Other examples include needed repairs for a home accessibility ramp when the individual financed the ramp and the ramp subsequently needs repair or maintenance.
RECOMMENDATION: Include in the definition that repairs and necessary maintenance to environmental modifications are allowable services, regardless of the funding source of the initial environmental modification.
Comment 38
Appendix C: Participant Services, C-1/C-3: Service Specification, Environmental Modifications, limits on the amount, frequency or duration of this service, narrative, 3rd paragraph, page 130
The standard requiring the modification to be provided “in the least expensive manner possible” is problematic. The standard can result in a ramp being built in a location that blocks ease and/or safety of access by other family members, which is uncovered resulting in the individual being exposed unnecessarily to the weather or the ramp being covered in icy and snow, or built on a path of travel that is not lit at night. The existing limit of $5,000 for environmental modifications is already a significant restriction to people receiving environmental modifications that can be independently used by the individual. The determination about how the modification should be designed and installed should be made by professionals with architectural, design and/or safety backgrounds and not constrained by an offsite analyst without this background.
RECOMMENDATION: Eliminate language that can restrict the provision of environmental modifications to a lesser modification than what has been recommended due to a cost effectiveness standard (least expensive manner possible) that minimizes the use of the modification.
Comment 39
Appendix C: Participant Services, C-1/C-3: Service Specification, Peer Mentor Supports, limits on the amount, frequency or duration of this service, 2nd paragraph, page 141
An unreasonable stipulation in the draft Application would require “all other available and appropriate funding sources must be explored and exhausted.” This standard does not apply to other FIS Waiver services. This is a requirement that cannot be reasonably assured, resulting in a reluctance for individuals and case managers to pursue this service.
RECOMMENDATION: Remove the sentence: “Prior to accessing funding for this waiver service, all other available and appropriate funding sources must be explored and exhausted.”
Comment 40
Appendix C: Participant Services, C-1/C-3: Provider Specifications for Service, Peer Mentor Administrating Agency, Provider Qualifications, page 142
DBHDS does not license Centers for Independent Living. Centers for Independent Living incorporated in the Commonwealth of Virginia must meet the requirements in Virginia Code, § 51.5-161.
RECOMMENDATION: Modify the Provider Qualifications item by listing Centers for Independent Living in the Other Standard block, not in the License block.
Comment 41
Appendix C: Participant Services, C-1/C-3: Service Specification, Skilled Nursing, Service Delivery Method, page 154
This item is inconsistent. The draft Application does not check boxes related to this service indicating that a relative or legal guardian can provide this service. Later in this section under Provider Specifications for this Service, there is language that would permit relatives and legal guardians to provide this service.
RECOMMENDATION: Clarify that a relative or legal guardian can provide skilled nursing services by checking the corresponding boxes in the item that specifies who can provide the service.
Comment 42
Appendix C: Participant Services, C-1/C-3: Service Specification, Supported Living Residential, Service Definition, narrative, 1st paragraph, 1st line, page 157
The definition starts with the following statement: “Supported living is residential supports that take place in a residential setting operated by…” The list of allowable activities include those that would be provided in the community such as skill-building related to community resources and supporting with transportation to and from places.
RECOMMENDATION: Clarify where supported living residential services may be provided.
Comment 43
Appendix C: Participant Services, C-1/C-3: Service Specification, Workplace Assistance, Service Definition, narrative, page 170
Refer to comment 18 above regarding the difficulty individuals have becoming or remaining employed due to the inability to access assistance for basic life functions such as eating, drinking and using the restroom. Four services can be used in an employment situation:
1. Individual Supported Employment that prohibits support with personal assistance.
2. Group Supported Employment that allows, “Personal care activities are not typically provided, but may be included.”
3. Personal assistant services reimbursed at a low provider rate virtually ensuring that no provider will commit to providing services in one-hour increments, leaving the work site, and returning later in the day for a one-hour service again. An individual could ask a co-worker to perform the personal care services, and then the co-worker take leave of their regular work duties to assist their co-worker with personal assistance. It is not typical in a professional working relationship for one employee to assist another with personal assistance such as using the restroom. This can become problematic for both co-workers.
4. Workplace Assistance is severely limited as an option for individuals who needs personal assistance due to restrictions in the draft Application including: “…nor may Workplace Assistance services be provided solely for the purpose of provision of assistance with ADLs.” The focus of Workplace Assistance is to “maintain stabilization” in employment. Workplace Assistance is one of the highest per hourly provider rate service. The assumption is that the service is not billed throughout the entire workday of the individual, but only when needed during certain parts of the day. The provider rate addresses the fact that this is an in-and-out service.
RECOMMENDATION: A service is needed that can reasonably be expected to be available when needed so that an individual who needs assistance with activities of daily living (ADLs) can be competitively employed without being limited to group support employment.