12VAC30 – 122-360 - Electronic Home-Based Support Service.

• B.1.- STRIKE “physically”. The section notes that the individual must be “physically” capable of using the equipment provided via EHBS service. Some EHBS services may be voice activated and not require physical manipulation. Although voice activation could be considered “physical”, this provision could be misunderstood and, thus, misapplied by authorizers or auditors.
• C.1. Recommend an increase to the cost of electronic home-based supports from the current maximum of $5,000 per calendar year.  This limit is not sufficient for up-to-date technology as well as any associated monthly monitoring fees. The purpose of these supports is to enable individuals who so desire to live more independently with less staff intrusion into their lives. The benefit should be consistent with the average cost of this type of support. If raising the overall limit is not feasible at this time, we recommend adopting a multi-year limit, such as $10,000 over the course of two years. This would allow greater flexibility for individuals to accommodate upfront costs of purchasing new electronic home-based supports technology without raising the overall multi-year dollar limits.

12VAC20-122-370 - Environmental Modification Service.

• C.2. Recommend an increase to the $5,000 annual limit for environmental modifications from the current maximum annual cap of $5,000 to a level deemed appropriate to the cost of such modifications. This limit is years old and it is increasingly difficult for families and individuals to secure modifications that will allow them to remain in their homes over their lifespan for this small amount of funding. If raising the overall limit is not feasible at this time, we recommend adopting a multi-year limit, such as $10,000 over the course of two years. This would allow greater flexibility for individuals to accommodate upfront costs of purchasing new environmental modifications without raising the overall multi-year dollar limits.
• C.6.- We recommend that an exception process be put into place for the uncommon circumstance in which the expansion of square footage to the home (which is prohibited) is an incidental result of a modification that will enable the individual to remain in the home ( e.g. a larger, accessible bathroom). Limits could be put into place for how much additional square footage would be allowable in an exceptions process.

12VAC30-122-380 - Group Day Service.

• B.1. Support the addition of the following that are included in the new CL waiver renewal application but are not currently included in the proposed final regulations:
  • Participation in community volunteer opportunities or education programs;
  • Staff coverage for transportation of the individual between service activity sites. Transportation is included as part of the service. The provider may be reimbursed for the time spent transporting the individual to community locations as part of the waiver billing
  • Personal types of activities (i.e. assistance with ADLs). These allowable activities are critical for individuals that need them but are not necessarily “skill building”.
  • Allowable activity of “providing safety supports in a variety of community settings”: This allowable activity is not included in the CL Waiver renewal application. Further, the CL renewal application includes “personal care types of activities (i.e. assistance with ADLs)” yet this allowable activity is not listed in either these proposed regulations nor in the “2016” version of regulations. These refer to activities rather than the requirement for skill-building; this phrase offers more flexibility for providers who are spending significant time in personal care than in skill-building. Consistent language should be included in these proposed regulations.
• C. Add 6. Recommend annual allocation for Group Day and Community Engagement hours to allow increased flexibility. Currently, Group Day hours and Community Engagement hours are authorized on a monthly basis with additional estimated “flex hours”. We recommend that there period of authorization be lengthened to allow more flexibility and consumer choice. For example, individuals choose whether they want to go out in the community or stay in a center on any given day. Because of weather or other personal circumstances of the individual, the individual may want to stay in the center more often in the winter and in the community more often in the Spring/Summer/Fall. Hours could then be drawn from a quarterly, semi-annual or annual “pool” of hours based on their person-centered plan.
• D.5. Supervision - There is NO reference to Licensing regulations to define “supervisor.” Licensing does not define a “supervisor” but does define a QDDP. The 2016 version of the Waiver regulations included the phrase “or a provider who has documented equivalent experience” to allow providers to substitute experience for a college degree, but this phrase is not included in either the new (2018) Licensing regulations or within the definition of QDDP in these Waiver regulations. Providers request consistency and clarity within and between regulations when defining QDDP since there are numerous QDDP responsibilities within these regulations.

12VAC30-122-390 - Group Home Residential Service.

• E.1.c- Change “at least a daily note” to “a Progress Note”. This makes it consistent with other requirements. See previous comments under “General Comments”.
• Move C.3 under letter D. It is under this section in other service descriptions.

12VAC30-122-400 - Group and Individual Supported Employment Service.

• Add Employment Services Organizations (ESOs) as qualified providers of Employment & Community Transportation Services.
• Add Employment Services Organizations (ESOs) as qualified providers of Peer Mentor Support Services.
• Add Employment Services Organizations (ESOs) as qualified providers of Community Guide Services.
• A.3.a. – Strike “limited” after but reimbursement shall not. (2nd sentence, 4th line)
• B.1. – Add “and enrolled in school” after for individuals younger than 22 years of age. Strike “for the individual enrolled in the waiver”.
• C.3. – Strike “and individual”. Individual SE must be able to be provided in an individual’s home for purposes of self-employment or other individuals that work from home for other employers (telecommuting, etc.)
• C.4. – Strike “service” after employment. Strike “in combination with other day service or residential service” and Change to “concurrently with other waiver services for purposes of job discovery”. Should read as follows: “For time limited and service authorized periods (not to exceed 24 hours) individual supported employment service may be provided in combination with concurrently with other waiver services for purposes of job discovery.” This revision helps with clarity.
• D.4. – Second paragraph under this Provider Requirements section is duplicative to 400.A.3.b (Service Description) and is not related to Provider Requirements.
• E.1.c. – Sentence needs to be reworked. “Documentation confirming the individual’s time in service” is for Group Supported Employment (GSE) only. “Daily note” is only applicable to GSE as well. Strike “daily note” and insert “progress note” to be consistent with other sections and definition of “progress note” in Section 122-20.
• E.1.f. - Sentence needs to be reworked. Should read “Documentation that indicates the date, type of service rendered, and the number of hours provided, including specific timeframe. An attendance log or similar document shall be maintained for Group Supported Employment”. An attendance log or similar document is not required for ISE since the individual is competitively employed.
• E.1.i. – After group, Insert “for Group Supported Employment”.

12VAC30-122-410 - In-Home Support Service.

• C5- Add “Back up plan may include agency support”. This is the most viable option for individuals who do not have a primary caregiver. While not specifically stated in the current regulations, families and individuals have historically been advised by case managers that the back-up plan must be a family member. Since an agency is providing the in-home service, it makes sense that a provider could also provide the back-up support. But, it should be optional and clarified that it is an option.
• Recommend that In-Home Services hours be authorized quarterly, semi-annually or annually – a “pool” of hours that would include and accommodate “periodic support hours”. Current regulations do not limit adding an average number of “periodic support hours”. However, in practice, this is an ongoing implementation issue with additional flexible hours not being approved. A longer period of authorization would help allow flexibility when an individual must stay home from group day or employment, community engagement. Most importantly, it supports choice.

12VAC30-122-420 - Independent Living Support Service.

• A – Add following receiving this service “lives, or is preparing to live, alone . . .”; strike “typically”. This service should be available to those planning to transition to more independent living and not just those already living independently.
• A- Add “or FIS waiver” at the end of the last sentence. There are individuals that wish to live independently in the FIS waiver who wish to live independently, particularly transition age you who could benefit from this service. It should not be limited to those already in an independent living setting.
• C.1.- Add “If the hours consistently exceed 21 hours per month, the individual shall be immediately eligible for a reserve slot.”
• 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”

12VAC30-122-430 - Individual and Family/Caregiver Training Service.

• A- Strike “FIS waiver” Add “in all of the DD waivers”. There is no reason that it is only included in the FIS waiver. Individuals and their families can benefit from this service.
• Strike C.1

12VAC30-122-440 - Nonmedical Transportation Service (Reserved).

• This service is now available (Medicaid Memo Sept. 4, 2018). It should be included in the final DD Waiver regulations and out for public comment.
• The name of this service needs to be consistent. Is it Employment and Community Transportation or Nonmedical Transportation Service. Needs to be consistent between DD Waiver renewals and regulations.

12VAC30-122-450 - Peer Support Service (reserved).

• This service is now available (Medicaid Memo September 4, 2018). It should be included in the final DD Waiver regulations and out for public comment.

12VAC30-122-460 - Personal assistance service.

• A.3. – Add “Personal Assistance can be provided simultaneously with supported employment services and can be billed concurrently”. The provision currently states that an additional component of personal assistance services is to aid and supports to individuals in the work place, with the final sentence stating, “Work related personal assistance service shall not duplicate supported employment service.” The addition of the suggested sentence at the end of this section clarifies that both can be provided at the same time and that they are distinctly different services.
• A.4- Change to “in all DD waivers”. As previously stated, it is unclear why this service is not available in the BI waiver. Individuals in the BI waiver are more likely individuals with physical developmental disabilities who may require personal assistance services in order to live independently in their homes. PA services can be critical to this population.
• C.7.a & b.- Strike “Companion” Add “Personal Assistance”. This is a typographical error.

12VAC30-122-480 - Private Duty Nursing Service.

• Support the recommendation by the Virginia Board for People with Disabilities (VBPD) that DMAS undertake an intensive review of all available data regarding the authorization of private duty nursing since the requirement to provide this service solely through EPSDT was put into place in order to determine, on a systemic level, whether families are being adequately served. The results of any study/review should be made public. Families that receive significantly reduced hours of skilled or private duty nursing or both can end up in a position where they would have to choose institutional over home and community-based care This is inconsistent with he requirement of the DOJ Settlement Agreement and incongruent with the stated desire to improve care and keep children at home with their families.

12VAC30-122-520 - Skilled Nursing Service.

• See comment above regarding Private Duty Nursing Service and support of the VBPD recommendation.

12VAC30-122-530 Sponsored Residential Support Service.

• 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”. This makes documentation consistent as previously stated.

12VAC30-122-540 - Supported Living Residential Service.

• First sentence - match the definition in section 122-20 to be consistent. DELETE “an apartment setting” and changing to a service “taking place in the individual’s own home.” Not all supported living residential settings areapartments.

12VAC30-122-550 - Therapeutic Consultation Service.

• B.2.i - Support Dr. Walker’scomments

• C.3- Strike “written preparation and telephonecommunication”

• D (1) Recommend adding Registered Behavior Technicians (RBT) to list of people that may providedirectsupportunderthesupervisionofBoardCertifiedBehaviorAnalyst.(RBT’swould not provide consultation, rather directsupport).

12VAC30-122-570 - Workplace Assistance Service (12VAC30-122-570).

• B.4. – Add (e) at the end of the lettered list which adds “Phone, media and in-person contacts with a Job Coach” as an allowable/billable activity. There may be times when a workplace assistant may need to consult with the individual’s job coach in order to meet the needs of the individual and to ensure consistency of strategies to support the individual to be successful in the workplace.

• D.3. – Providers of Workplace Assistance that are CARF accredited employment vendors of DARS satisfy staff competency requirements for Workplace AssistanceServices.

• Recommend that Workplace Assistance Services be added to the BI Waiver as individuals onthis Waiver may have health and/or safety monitoring needs in a place ofemployment.