12VAC30-50-440 (Support Coordination and Service Facilitation

RECOMMENDATION:  Multiple changes for an equitable system for ID/DD (Support The Arc of VA Statement)

• 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.

• 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.  

• The regulations allow individuals transferring from institutional to community settings to receive 90 days of paid Support Coordination if they have a developmental disability, but only 60 days of paid Support Coordination if they are in the same situation but have an intellectual disability diagnosis.  These timelines should be identical and should reflect the average time it takes individuals to plan and complete a discharge from institutional settings.

12VAC30-122-20 – Definitions (Support vaACCSES Positon)

“Progress Notes” - DELETE language indicating that progress notes are signed and dated on the day the supports were provided and REINSTATE previously utilized language that indicates “progress notes are signed and dated as soon as is practicable but no longer than one week after the referenced services.”

12VAC30-122-60 - Financial Eligibility Standards for Individuals (Support vaACCSES Positon)

Recommend Spend-down for all Long-term Care waiver categories. This language is already in the CCC+ waiver. This language should be moved to all categories.

12VAC30-122-80 - Waiver Approval Process; Authorizing & Accessing Services (Support vaACCSES Positon)

C. AMEND - 30 calendar days to no later than 90 calendar days for individuals assigned slots to meet with their Support Coordinators.   This will allow individuals to avoid Medicaid redetermination.

Waiting List and Eligibility (Support The Arc of VA Position)

12VAC30-122-90 Waiting List D. 1. 

RECOMMEND: Add age criteria for Priority 1 to include caregivers age 75 years and older and add people age 65 years and older who are on the DD Waiver Wait List.

For individuals on the waiting list, we have concerns about the age of the primary caregiver(s) and the age of people on the waiting list 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.  There are currently 14 people over age 65 in priority one of the waiting list, and an additional 64 in priority two and 23 in priority 3.  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 the age eligibility for Priority One reduces the odds that the person with a disability will be able to access services before their caregiver dies. Similarly, people who are on the waiting list who are 65 years or older are usually without natural supports and caregivers and they are most likely dealing with the effects of aging.  They require waiver services that address the need for community engagement, personal care, companionship and close monitoring of their physical and mental health conditions.  At age 65 people on the waiting list should be assigned an appropriate waiver.  We propose that the age of the caregiver and the age of the person on the waiting list be considered as a factor in determining eligibility for Priority One of the waiting list.  Without needed waiver services people are at high risk for nursing facilities or institutional placement. 

12VAC30-122-90 G.2 (Support The Arc of VA Position)
RECOMMEND: Implement a process for waiver transfers that prioritizes the urgency of need. 

For individuals who need to transfer from one Waiver to another Waiver offering a higher level of services, urgency of need should be considered.  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.  

12VAC30-122-120 - Provider Requirements (Support vaACCSES Positon)

Provider Requirements - Quarterly Reviews: This will make the DD Waiver Regulations consistent with the current licensing Regulations 12VAC35-105-675 - Reassessments and ISP Reviews.
ADD - “Documentation of the quarterly review shall be added to the individual’s record no later than 15 calendar days from the date the review was due to be completed with the exception of case management activities. Case Management quarterly reviews shall be added to the individual’s record no later than 30 calendar days from the date the review was due.” 

A.5. - ADD “as appropriate”. Training on Crisis Education and Prevention Plans is not applicable to all waiver services. Also, clarity is needed as to whether this is for licensed providers only “as appropriate” or for all providers “as appropriate.”

A.12.c (4) e. - DELETE language that requires “such documentation shall be written, signed and dated on the day the described supports were provided”. INCLUDE language, consistent with the previous language under 122-20 “Progress Note” definition, that “progress nots are signed and dated as soon as is practicable but no longer than one week after the referenced service”.

A.12.c. (4) e. - ADD “electronic signature as acceptable for providers using Electronic Health Records (EHR) programs”.

A.12.c. (4) f. (4) - Clarification regarding the term “individual’s unique options”. We assume that this means opinions about their individual supports’ options”. However, clarity is needed.

A. 19. - MODIFY this semi-annual supervision note requirement for DSP and supervisor of DSPs as “required after the first six months of employment and regularly thereafter.”

12VAC30-122-200 - Supports Intensity Scale Requirements, Virginia Supplemental Questions; Levels of Support; Supports packages (Support vaACCSES Positon)

4.D. DELETE this subsection.  Chapter 854, Acts of the 2019 Assembly prohibits the implementation of support packages unless specifically authorized by the General Assembly.

ADD - Appeal process for SIS score. Because SIS assessments are only made every 2, 3 or 4 years depending upon the age of the individual, individuals and their families must be able to appeal the results and present additional or alternative evidence. SIS scores and results are subjective according to the administering agency selected by DBHDS. There must also be flexibility to request a new SIS assessment any time between 2,3, or 4 year requirements when circumstances warrant because of changes in an individual’s needs - especially behavioral or medical support needs.

12VAC30-122-210 A.4 Payment for covered services (Support The Arc of VA Position)

RECOMMENDATION: Add all employment and nursing services to services eligible for customized rates.

The current regulations only allow customized rates in community coaching, 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. 

12VAC30-122-390 Group Home Residential Service (Service Description) (Support VNPP Position)

The language restricts the number of licensed beds for group home residential to 6 (six) or fewer.  We do not operate large settings; however, the level of support is dependent on several factors.  They include, but are not limited to:

the reimbursement rates paid by Medicaid

the current workforce shortage due to low wages

wage or benefit mandates that drive costs higher

other inflationary factors such as insurance, maintenance, utility costs, etc.

Providers have suffered years of flat rates while at the same time wanting to downsize homes.  Economically, this cannot occur because there is a lack of adequate funding to support smaller homes.              

12VAC30-122-410 In-Home Support Services (Support vaACCSES Positon)

B.4. - REVERSE and REINSTATE Stricken Language

EXPLANATION: In-Home Support Services needs the flexibility of episodic supports for all the reasons stated in the stricken language.

12VAC30-122-440 - Nonmedical Employment and Community Transportation Services (Support vaACCSES Position)

Although a critical and needed service, the service as written is operationally a nightmare. This includes documentation requirements, supporting documentation such as “Google Maps/MapQuest print-outs to support trip mileage”, driver requirements, and no administering agency overhead reimbursement for administration. There are also cost reimbursement issues that do not reflect current rates via public transportation, etc.

12VAC30-122-540. (Supported living residential service) (Support Arc of VA Position)

RECOMMENDATION:  Remove “setting operated by provider”.

The new service of Supported Living was hoped by many people with disabilities, families and advocates to be the alternative to provider owned group/sponsored homes, for people with high support needs to receive up to 24 hours of support but in their own home.  

Continuing to tie the setting to the provider rather than to the person does not adhere to the HCBS settings rule by allowing the person to have control over their home environment including the ability to hire and fire service providers.  If a person has to move in order to choose a different provider, then their home was never their home.  

 12VAC30-122-560 - Therapeutic Consultation Services (Support vaACCSES Positon)

 RECOMMEND that Therapeutic Consultation Services be provided to individuals on the Building Independence Waiver to further create and maintain independence and inclusion for individuals living and working in the community

E.1. (2) e. (1) - MODIFY the requirement of “the quarterly review shall include graphed data and a summary of the data”. ADD “as appropriate.”  Graphing is specific to one model only. Broader language in this section will allow for ever changing best practices.

12VAC30-122-570 - Workplace Assistance Service (Support vaACCSES Positon)

RECOMMEND adding this service to the Building Independence Waiver. There are individuals with significant support needs related to health and safety or job maintenance that may need this level of flexibility in supports to maintain their employment.

B.4. ADD “telephonic or virtual communication with the job coach” as an allowable activity to ensure effective service delivery.