Regulation

Concern/Question

12VAC30-122-20 Definitions

"In-home support services" means residential services that take place  [ primarily ]  in the individual's home, family home, or community settings that typically supplement the primary care provided to himself or by family or another unpaid caregiver and are designed to enable the individual to lead a self-directed life in the community while ensuring his health, safety, and welfare.

Remove ‘typically supplement the primary care provided to himself or by family or another unpaid caregiver and’.

This definition is contradictory to the HCBS rule that requires individuals to have the choice to live in the least restrictive environment.  This definition clearly insinuates that only those who are able to be their own primary care giver or who have someone else as the primary caregiver are the typical users of this service.  It should coincide with the HCBS rule and be inviting to everyone as an option.

"Therapeutic consultation" means professional consultation provided by members of psychology, social work, rehabilitation engineering, behavioral analysis, speech therapy, occupational therapy, psychiatry, psychiatric clinical nursing, therapeutic recreation, physical therapy, or behavior consultation disciplines that are designed to assist individuals, parents, family members, and any other providers of support services with implementing the individual support plan.

The definition here should match the description of who can provide this service in the following section: 12VAC30-122-550 Therapeutic consultation service

A. Service description. Therapeutic consultation service means professional consultation provided by members of psychology, social work, rehabilitation engineering,  [ behavioral behavior ]  analysis/consultation, speech-language pathology therapy, occupational therapy, psychiatry, psychiatric clinical nursing, therapeutic recreation, or physical therapy disciplines that are designed to assist individuals, parents, guardians, family members, and any other providers of support services with implementing the individual support plan.

12VAC30-122-120 Provider requirements

D. Providers with a history of noncompliance, which may include [ (i) ] multiple records with citations of failure to comply with regulations [ or , (ii) ] multiple citations related to health and welfare for one [ service support ] plan [ ; or (iii) citation by either DMAS

It is not clear concerning the length of time analyzed to determine a history of noncompliance.  This leaves it open to interpretation by each licensure specialist.  There is also no mechanism to ensure this is applied equitably among providers based on a ratio of the number of people supported.  A 6-bed group home with multiple citations is much different from a provider that supports 150 people in their own homes.

12VAC30-122-190 Individual support plan; plans for supports; reevaluation of service need

2. Components of annual person-centered plan review. E. e. ]  A new psychological or other diagnostic evaluation shall be required whenever the individual's functioning has undergone significant change,

This section does not specific who is responsible for seeking this new psychological when functioning undergoes significant change.  It seems the Waiver is pushing for guardianship. 

12VAC30-122-210 Payment for covered services (tiers)

C. Reimbursement for assistive technology (AT) service (12VAC30-122-270), electronic home-based support service (12VAC30-122-360), environmental modifications (EM) service (12VAC30-122-370), individual and family/caregiver training service (12VAC30-122-430), and transition service (12VAC30-122-560) shall be reimbursed based on approved costs subject to the following limits:

1. AT and EM approved costs for items and labor shall be reimbursed up to a per individual [ , per service ]  maximum of $5,000 per calendar year across all home and community-based waivers.

2. Transition services approved costs shall be reimbursed up to a per individual maximum of $5,000 per lifetime across all home and community-based waivers.

3. Electronic home-based support approved costs shall be reimbursed up to a per individual maximum of $5,000 per  [ calendar ISP ]  year.

These reimbursement caps have not been adjusted for inflation in x amount of years significantly decreasing the resources available to individuals each year.

Construction costs have continued to increase at record rates over the past year.  The cost of materials for environmental modifications is higher than it has ever been.  Allowances need to be made to cover this increased cost.

The process for contractors to submit quotes is cumbersome, and the wait for reimbursement can be long.  This means the best contractors are often not those who are willing to provide this support.

12VAC30-122-410 In-home support service

A. Service description. In-home support service means a residential service that takes place in the individual's home, family home, or community settings that typically supplement the primary care provided by the individual, family, or other unpaid caregiver and is designed to ensure the health, safety, and welfare of the individual. The individual  [ shall be enrolled in either the FIS or CL waiver and ]  shall be living in his own home or his family home. This service shall include a skill building (formerly called training) component, along with the provision of supports that enable an individual to acquire, retain, or improve the self-help, socialization, and adaptive skills required for successfully living in his community. In-home support service shall be covered in the FIS and CL waivers.

Remove ‘that typically supplement the primary care provided by the individual, family, or other unpaid caregiver and’.

This definition is contradictory to the HCBS rule that requires individuals to have the choice to live in the least restrictive environment.  This definition clearly insinuates that only those who are able to be their own primary care giver or who have someone else as the primary caregiver are the typical users of this service.  It should coincide with the HCBS rule and be inviting to everyone as an option.

[ 4. Authorized to provide additional episodic supports when there is a change in the individual's routine schedule, such as the cancellation of work or a day activity because of a holiday or inclement weather, or support is required in accompanying an individual to a medical appointment. An estimate of the monthly requirement for episodic supports should be included in the initial authorization request. Authorized hours for episodic supports shall only be reimbursed when the service is rendered and supported by documentation. ] 

ADD back in the allowance for episodic supports.

In-Home providers often become the support provider during holidays and when someone is ill.  There is currently no mechanism for providers to be able to assist in these situations and receive any type of payment.

C. 2. In-home support service shall not typically be provided 24 hours per day but may be authorized for brief periods up to 24 hours a day when  [ medically ]  necessary.

Strike this entire section! Some individuals will require up to 24 hours of support and this should not prevent them from living in their own home.

This definition clearly insinuates that only those who are the most independent are able to live in their own home.   It should coincide with the HCBS rule and be inviting to everyone as an option.

12 VAC30 122-200

Supports Intensity Scale requirements

D. Establishment of support packages, which means, a set of assumptions regarding the types and amount of supports that an individual needs to be adequately supported in the community.  It is a model that reflect reasonable services levels based on common expectations for person who share similar characteristics.

“Reasonable services levels based on common expectations for persons who share similar characteristics” is absolutely the opposite of person-centered planning.  The state has spent so much time, money and energy to get everyone trained on how to develop plans and supports catered to each individual, and now we are going to lump everyone into one of 4 basic categories based on a test score that doesn’t truly measure individual needs.  This should be struck from the regulation.  It is solely a cost control method that is the antithesis of person-centered practices. 

12VAC30-122-330

Community guide services

Service units and limitations:

1.  May be authorized for no more than 6 months at a time.

This does not work well with the current WaMS system as housing needs do not often coincide with annuals, and services can’t be authorized more than 30 days prior to beginning the service. (per other regulation).  This means an undue burden to the Community Guide-Housing provider due to having to submit an interim plan in WaMS, which requires more work.  Due to this regulation, providers will have to do more Interim Plan for Supports to be added to an individual’s ISP to complete CHG services during their housing renewal period.

Tenant Screening Form

This form is only applicable to those who are moving from congregate settings into an apartment of their choosing, moving out of family homes into an apartment of their choosing, and/or wanting to move from current apartment to another apartment complex.

This form is not applicable for those who have secured independent housing in the community and want to continue to live in their current apartment

Community Housing Guides services conducted not in the presence of the individual shall not comprise more than 25% of authorized plan for support hours.

The review of the housing recertification process, tenant education, and tenant screening/housing road maps are completed with the person, which is about 25% of the CHG work.

The other 75%, outreach to potential landlords, completing recertification paperwork, acting as a liaison between the PHA, landlord, and client are all services that are conducted on behalf of the individual.

A lot of the CHG work is completing paperwork, contacting landlords, research, and working with local PHA which is all done without the individual present. It would be difficult to conduct these services with the individual over 25% of the time. This can cause problems with the client and the provider. Based on our experience, around 75% of the work would be completed on behalf of the client. PHAs do not meet with established HCV/PHA clients who have a housing representative. They allow the representative to act on their behalf and complete the work without having the client attend meetings. Additionally, landlord do not meet with clients regularly. They allow the CHG representative to act as a liaison for the client and communication is electronic, virtual, and infrequently in person.

Explore the possibility of using technology to virtually meet with the client for comfortability and practicality. The CHG can conduct “check ins” with client to provide them an update on the task/allowable activities being completed. This will allow for the client to be informed on the services provided, while allowing the CHG to continue to work for the client without continuous meetings or having them present while paperwork is being completed.