Staff Requirements:

1. A full-time Program Director with Clubhouse International training as described in section 3.3 who holds a current, active, and unrestricted Virginia registration or license from the Department of Health Professions that qualifies them as a QMHP, LMHP, LMHP-R, LMHP-RP, or LMHP-S.
2. A Licensed Mental Health Professional (LMHP) who holds a current, active, and unrestricted Virginia license from the Department of Health Professions that qualifies them as a LMHP, with Clubhouse International training as described in Section 3.3. The LMHP does not need to be a full-time employee and shall be available on call or as needed. The LMHP shall have the ability to provide in-person services and support to members and staff.

There is no clarfication on if these can be the same people, or if they have to be different people. This will be challengeing with the shortage of licensed providers. 

Staff Training Requirements

1. All staff are required to receive training as required by Clubhouse International.
2. All newly DMAS enrolled Clubhouses shall send a team (including at least one member) to an authorized Clubhouse International training base within the first 12–18 months of operation, and staff are expected to participate in training or specialized tracks as a condition of maintaining accreditation in good standing.

Will there be supplemental funding provided to support these? They are all out of state and require significant time away from regular work and family duties. How long do we have before every staff must be trained? Does everyone need to be trained or just the program director? Is there an expectation of continued training every so many years or can one staff go and be done forever?

Crisis Planning: “When a member is not present at the Clubhouse, crisis support shall be guided by the member's individualized crisis plan. The plan shall be designed to be utilized in the member's community setting and shall specify actions the member, natural supports, and Clubhouse staff can take when the member is not on-site, including contact protocols, de-escalation strategies, and referral pathways to appropriate crisis services including but not limited to 911, 988, Emergency Room, CSB Emergency Services, 23-Hour Crisis Stabilization, and Residential Crisis Stabilization Unit”

Why are we responsible for things that happen outside of our program?

Will there be training on crisis planning provided? Is this training being left up to the CSB's or will there be state training?

“When a member is present at the Clubhouse during program hours and a crisis occurs, the Clubhouse shall provide immediate, on-site crisis support. At least one staff qualified to provide crisis support shall be available in-person during all program hours to respond to member crises without delay.”

What constitutes a qualified staff person in this scenario? The LMHP? What if they are out of the office? Do QMHPs count?

"Providers shall submit service authorization requests within one business day of admission for preservice service authorization requests and by the requested start date for concurrent stay requests. If submitted after the required time frame, the start date of authorization will be based on the date of receipt."

This is an incredibly short turn around, and what happens if the authorization is rejected? Do we then have to discharge the individual right after enrollment?

The individual's MCO/FFS service authorization contractor conducting the service authorization review may approve the requested service(s) or may recommend a more clinically appropriate service based on their review.

 This still gives too much power to the MCOs, and makes more work for the provider. Person centered programs are about what the client wants, not what the insurance says they need. 

All service authorizations shall be issued for a six (6) month period. Each authorization shall include 120 units of H2031.

Currently we usually request 360-468 units for someone who attends every day for 8 hours a day. This is a dramatic reduction in what we currently bill. We would loose money this way. 

Paperwork: Daily, Weekly, Monthly: The level of detail this is laying out is nearly imposible for us who have 30-35 members every day. Too much staff time will be taken up by this. And its very redundant. 

Sec 8.1 LMHP Review: What is the reasoning for making LMHP's have to sign off on all QMHP documentation? This takes away power from the QMHPs and adds additional administrative burden on the LMHPs. 

Current rate is $89. Per diem rate is $74. Our program, and I believe many others would loose significant revenue this way. Especially if we can only bill for specific activities and not for members in the building who are less active participants but just  need a quiet space to sit and think/reflect.

Caliber Virginia appreciates the opportunity to provide feedback on the proposed Mental Health Clubhouse Services as part of the Commonwealth’s Right Help, Right Now behavioral health redesign initiative. We recognize the value of psychosocial rehabilitation and community integration models and support the inclusion of diverse service options within Virginia’s behavioral health system.

However, we have several concerns regarding the structure and implementation of the proposed Clubhouse model and its potential impact on service delivery, workforce stability, and access to care.

First, the Clubhouse model represents a significant shift away from traditional, higher-intensity rehabilitative services. The emphasis on group-based, work-ordered day programming and a staff-to-member ratio of up to 1:20 may reduce the level of individualized support available to members. Many individuals currently served through high-touch, community-based services require consistent, hands-on interventions to maintain stability. A reduction in individualized attention may increase the risk of disengagement, decompensation, and utilization of higher levels of care.

Second, the staffing and leadership requirements may present challenges for provider sustainability. The requirement for a full-time Program Director with specialized training, along with ongoing Licensed Mental Health Professional (LMHP) involvement, introduces additional staffing costs. Given current workforce shortages, particularly among licensed professionals, these requirements may limit the number of providers able to successfully implement this model.

Third, the proposed documentation and operational requirements represent a notable increase in administrative burden. The introduction of daily attendance logs, weekly progress notes, structured service planning timelines, supervision requirements, and ongoing accreditation processes will require significant administrative oversight. While accountability is important, these expectations may divert resources away from direct service delivery if not supported by appropriate reimbursement structures.

Additionally, the requirement to obtain and maintain Clubhouse International accreditation introduces both financial and operational challenges. Smaller and community-based providers may face barriers in meeting accreditation timelines and requirements, which could reduce provider participation and limit geographic access to services.

We also note the importance of ensuring that the Clubhouse model is implemented in a way that supports equitable access. Individuals in underserved communities may face barriers to consistent participation in structured, location-based programming due to transportation, employment, and family obligations. Flexibility within the model will be critical to ensure these individuals are not unintentionally excluded.

Recommendations:

Caliber Virginia respectfully recommends the following:

• Maintain flexibility in staffing ratios to allow for increased individualized support when clinically appropriate
• Align reimbursement with administrative, supervision, and accreditation requirements
• Provide phased implementation timelines to support provider readiness and workforce development
• Offer flexibility in program structure to accommodate individuals with barriers to daily participation
• Consider alternative pathways for accreditation or extended timelines for smaller providers

Caliber Virginia remains committed to working collaboratively with DMAS to ensure that the implementation of Mental Health Clubhouse Services enhances access to care while maintaining service quality, workforce stability, and provider sustainability across the Commonwealth.

The current draft remains too onerous for many agencies to implement, particularly in light of the reimbursement rates.  Programs will close, and I remain concerned about the quality of life and stability of those who will lose a valuable resource.  Current PSR programs fill a vital role in the continuum of care, particularly for those whose functional abilities are severely impaired by their mental illness.  I am sad to see this level of care "sunset".

AHCS appreciates the opportunity to provide feedback on the proposed Mental Health Clubhouse Services. Below are several concerns regarding the proposed Clubhouse Model. 

3.1 Staff requirements 

• The staffing and leadership requirements may present challenges to sustainability. The requirement for a full-time program director with specialized training in conjunction with a LMHP, increases additional financial burden. With LMHP workforce shortages, these requirements may limit some from implementing a sustainable model. 
• Staff to member ratio shall be one staff to 20 members or fewer during program hours. This will reduce the individualized supports with emphasis on group-based programming. 
• The required staff training required by the Clubhouse International Model - will funding be available? What is the expectation for the training - all staff, program director, & how often etc. The rate of reimbursement does not support staff training requirements, please consider rate of reimbursement review.

3.4 Licensing and Enrollment Requirements

• If PSR requires external accreditation for the Clubhouse International Model, consideration for alignment with DBHDS licensing requirements to reduce the administration burden for annual reviews. 

3.6 Clubhouse Operation Requirements

• The requirement for an independent board of directors may be a difficult requirement for CSB's who already have an existing Board of Directors. Please consider an advisory council of program leadership and members in place of the independent board of directors. 
• Clarification is needed for holidays accepted by the  Clubhouse International Model, most CSB's have existing holidays embedded in their operations. 

Thank you for allowing us the opportunity to offer recommendations to this policy. We have reviewed all policy changes and have the following recommendations.

3.1 Clubhouse Staff Requirements

The policy states a full-time Program Director with the Clubhouse International training who holds a current, active, and unrestricted Virginia registration or license from the Department of Health Professions. Recommend that it offers flexibility that it be from program leadership and not specifically the Director of the program.

3.3 Staff Training Requirements

The policy states all staff are required to receive training as required by Clubhouse International and all newly DMAS enrolled Clubhouses shall send a team to an authorized Clubhouse International training based within the first 12-18 months of operation, and staff are expected to participate in training or specialized tracks as a condition of maintaining accreditation in good standing. The rate of reimbursement does not support staff training requirements. Recommend that this be further reviewed considering the initial 2-week duration of training and staff turnover.

3.4 Licensing and Enrollment Requirements

The policy states that providers shall submit with their DMAS enrollment application evidence of their initiation of the accreditation process or their formal accreditation with Clubhouse International. However, if the service requires external accreditation for "Clubhouse International", there should be consideration for alignment with DBHDS licensing requirements to reduce administration burden for annual reviews.

3.6 Clubhouse Operation Requirements

The policy states the Clubhouse shall have an independent board of directors, or affiliated with a sponsoring agency, shall have a separate advisory board comprised of individuals uniquely positioned to provide financial, legal, legislative, employment development, consumer and community support and advocacy for the Clubhouse. However, an independent board of directors' requirement is a difficult requirement for CSBs who have existing board of directors. Recommend that you consider an advisory council comprised of program leadership and members.

4.2 Service Planning

The policy states at a minimum, the ISP shall be signed within 30 days of admission and 15 days of an ISP review by the Program Director or LMHP/LMHP-type performing the assessments. The Clubhouse International Model is not a clinical service, therefore, recommend allowing the staff providing the service to sign it instead of the Program Director or LMHP.

4.4 Crisis Support

The policy states when a member is present at the Clubhouse during program hours and a crisis occurs, the Clubhouse shall provide immediate, on-site crisis support. At least one staff qualified to provide crisis support shall be available in-person during program hours to respond to member crisis without delay. Recommend clarifying individualized service plan requirements and what qualifies a person to provide crisis support.

8.3 LMHP Review

The policy states that an LMHP must review the documentation of all non-LMHP staff at least every 30 calendar days. However, this is not a clinical service and recommend it be sufficient for the staff providing the service to review and sign the documentation every 30 calendar days.

The requirements around the Clubhouse model continue to be concerning, prohibitive, and may result in no resources for this service throughout Virginia.  

• limited to only one model, Clubhouse International, which presents multiple challenges.
• Implementation costs are prohibitive--Accreditation is very costly, as well as training costs around $10,000, which won't be covered by this reimbursement rate. 
• Clubhouse has to be in separate buildings, no shared space with other programs.  This is limiting in multiple ways for providers, but also for individuals. 
• Full accreditation is required within 3 years
• The model is very urban area-oriented and individual run/lead.
• it also holds additional staff requirements which are challenging in some parts of the state. 

Thank you for proving us the opportunity to offer recommendations to the proposed regulation changes. We have reviewed the changes and have the following recommendations: 

3.3 Training Requirements & 3.5 Provider Accreditation

The staff training requirements and provider accreditation cost do not match the rate of reimbursement. The additional cost and administrative burden is not budget neutral nor sustainable for Clubhouse programs to remain operational. 

4.2 Service Planning

The proposed regulation states at a minimum, the ISP shall be signed within 30 days of admission or 15 days of an ISP review by the Program Director or LMHP/LMHP-type performing the assessments. The Clubhouse International Model is not a clinical service, therefore, recommend allowing the staff providing the service to sign the ISP instead of the Program Director or LMHP. With the shortage of LMHP or LMHP-type, this is an unnecessary burden.

4.4 Crisis Support 

The proposed regulation states when a member is present at the Clubhouse during program hours and a crisis occurs, the Clubhouse shall provide immediate, on-site crisis support. At least one staff qualified to provide crisis support shall be available in-person during program hours to respond to member crisis without delay. Recommend clarifying what qualifies a person to provide crisis support. 

8.3 LMHP Review

The proposed regulation states that an LMHP must review the documentation of all non-LMHP staff at least every 30 calendar days. However, Clubhouse is not a clinical service and recommend it be sufficient for the staff providing the service to review and sign the documentation every 30 calendar days. With the shortage of LMHP or LMHP-type, this is an unnecessary burden. 

3.3 Staff Training Requirements The rate of reimbursement does not support staff training requirements, therefore this needs to be further reviewed considering the initial 2-week duration of training and staff turnover.

Please provide clarification on the frequency of staff training requirements, i.e. annual.

7.2 Service Authorization Period and Unit Allocation The need for stability is not addressed for individuals.

9.1 Mental Health Clubhouse Services Billing Code Rate does not support the various cost requirements including, but not limited to accreditation, staff training, and facility costs.

Please see comments and suggestions to Clubhouse draft regulations below - 

Service Definitions:

The definition of SMI should be updated to state Schizophrenia “spectrum” and/or psychotic disorders rather than just schizophrenia.

Staffing:

If an LMHP is required, then Clubhouse International training should not be for this position. Clubhouse does not require this level of oversight and the length and cost of training is not factored into the per diem rate for this level of employee. If a licensed type is required in any capacity, this should allow for an LMHP-E (while under supervision of an LMHP). If the program director is trained by Clubhouse International, that level of training should suffice for facilitation of the program element and the LMHP-type would serve solely to address clinical needs and clinical guidance rather than Clubhouse specific elements.

Training:

Please consider elaborating on 3.3.1 about staff receiving training as required by Clubhouse International. If a program director and initial team have been sent to Clubhouse International training, this should be sufficient for the training requirement and any additional staff should be permitted to be trained by program director.

Assessment:

Clarification around the annual assessment requirements would be helpful. For example, in 4.1.5 it says an annual assessment is required – but could this be an addendum? Additionally, 4.1 it says an assessment is “Face-to-face” but in 4.1.1, it says an in-person assessment is required. Updates to clarify where telemedicine is appropriate would be helpful. Assessments in general, should be permissible via telemedicine or telemedicine assisted to better expand care to geographic regions with less LMHP types available.

ISP:

90-day ISP review for Clubhouse is excessive. Consider extending timeline to better meet the other requirements. I.e. annual ISP review to align with annual assessments and/or authorization requirements.

Additionally, consider allowing the crisis plan to be a separate document from the ISP.

Crisis Plan:

90-day review of crisis plan is too frequent for this level of service. Consider altering requirement to state at least annual review and upon clinical necessity (i.e. in the event of a known crisis).

Admission Criteria:

The CNA requirements listed here are contradictory to the Assessment language listed in section 4.1. These sections should be aligned to better reflect the initial assessment requirements.

Diagnostic Criteria should include Depressive Disorders at this aligns with the service definition of SMI. A diagnosis of major depression should not require a physician letter for access to care.

Exclusions:

Consideration that Autism Spectrum Disorder as sole diagnosis (when meeting the other service criteria) be permissible as Clubhouse International is an exceptional program for individuals with Autism and at times is more clinically appropriate than a waiver support.

Service Authorizations:

Per Clubhouse accreditation, Clubhouses should be working towards 7-day programming including holidays. To meet this requirement, authorization for 182 units per 6 mos would be required. Currently, our program operates 6 days per week and some individuals attend all 6 days. The current draft authorization recommendation would limit individuals accessibility to program elements and would not be acceptable according to Clubhouse International Standards.

The requested details for a concurrent authorization in the first 24 mos of services is overly burdensome. Consider consolidation of requirements to a specified form or inclusion of most recent ISP review instead during the first 4 continued stay requests.

Documentation Requirements:

Daily log of ISP goal and service component in addition to a weekly progress note as currently outlined is excessive for this level of service. Consider one of the following approaches instead: Daily note as outlined in 8.1 and a monthly progress report narrative addressing the ISP progress. OR a Daily log of member name, date, time in/out/duration, staff signature/credentials and weekly progress note addressing ISP goals and service components only. The Attendance table being included in the weekly (or monthly if considered) note is redundant to the daily log requirements and should be omitted entirely. Again – the narrative section for the weekly note is excessive for this level of service and should be reduced.

In general, the documentation requirements for Clubhouse per this draft are excessive and do not adequately reflect the clinical level of service or reimbursement rate. Consider consolidation where able.

LMHP-Es should be permitted to review documentation as well. LMHP-Es are more than qualified to co-sign and supervise the documentation of Clubhouse International Staff.

 General Billing Requirements:

Please consider elaborating on 9.2.a-b to clarify that point b is not required in entirety to bill per diem as it’s not entirely clear.

As an LMHP responsible for implementing this policy, I cannot comply with both its clinical requirements and its mandated accreditation standards without creating an operational conflict with my professional obligations.

I am a Licensed Clinical Social Worker co-supervising a psychosocial rehabilitation program serving individuals with serious mental illness, including individuals with high-risk histories and NGRI status. I submit this comment to place on record that the requirements described in the draft manual, when implemented alongside Clubhouse International accreditation standards, create a structural conflict in practice for licensed clinicians. I am concurrently submitting a formal request for advisory guidance to the Virginia Board of Social Work regarding my professional obligations under this framework.

1. Structural implementation conflict

The draft manual establishes a service model requiring LMHP oversight, clinical assessment, individualized service planning, rehabilitative intervention, and crisis support. These requirements reflect a clinically defined service structure.

However, when implemented alongside Clubhouse International accreditation standards, an operational and professional conflict emerges for LMHPs.

Clubhouse International explicitly states that “the role of the staff in a Clubhouse is not to educate or treat the members” (Source: https://clubhouse-intl.org/what-we-do/what-clubhouses-do/). This reflects a non-clinical service model.

In practice, these requirements establish divergent expectations:

• DMAS requires LMHP-directed clinical oversight, assessment, and intervention

• Clubhouse accreditation requires a non-clinical environment in which staff do not provide treatment or educational services

When applied simultaneously, these frameworks impose conflicting operational requirements regarding the role of staff, the scope of supervision, and the permissible nature of clinical engagement.

2. Clinician obligations under Virginia law

Licensed Clinical Social Workers in Virginia are bound by 18VAC140-20-150, which establishes that:

• Protection of public health, safety, and welfare is the primary professional obligation (A)

• Practice must be consistent with professional standards and within the boundaries of competence (B)(1), (B)(3)

Virginia’s standard of care statute (Va. Code § 8.01-581.20) further establishes that clinicians are held to the level of care exercised by a reasonably prudent practitioner under similar circumstances. This obligation is independent of program structure or funding mechanism.

Together, these requirements obligate LMHPs to exercise clinical judgment and respond appropriately when clinical need is identified within their scope of competence.

3. Operational consequence

DMAS requires clinical supervision and individualized clinical oversight within this service model. Clubhouse accreditation standards, specifically Standard 8, do not contemplate or support clinical supervision structures that involve treatment-oriented case formulation or intervention planning (Source: https://clubhouse-intl.org/wp-content/uploads/2025/11/Standards_2025_english.pdf).

As implemented, this produces an operational conflict in which compliance with accreditation requirements constrains the clinical functions that DMAS simultaneously requires under LMHP-level service delivery.

This is not theoretical. It is a structural implementation conflict that emerges in practice under dual compliance requirements.

4. Professional position

My obligations as a licensed clinician are defined by Virginia law and professional regulation. They are not modified by program designation or accreditation requirements.

When a service model requires compliance with accreditation standards that constrain clinically indicated practice, while simultaneously requiring LMHP-level clinical oversight, it creates a structural conflict in implementation that cannot be resolved at the individual clinician level.

This also creates a conflict between required accreditation attestation and the actual clinical conditions under which services are delivered. Licensed professionals are placed in a position where attesting to compliance with external accreditation standards are not reconcilable with the requirements of professional licensure and the real-world execution of clinical duties.

5. Requested action

Based on the structural and professional conflict outlined above, I request that DMAS reevaluate compatibility of mandated Clubhouse accreditation requirements with LMHP clinical practice obligations under Virginia law, and consider the material impact of this framework on licensed clinicians who are ethically and legally responsible for its implementation in real-world service settings.

The Hampton Newport News Community Services Board appreciates the opportunity to provide feedback on the proposed Mental Health Clubhouse Services as part of the Commonwealth's Right Help, Right Now behavioral health redesign initiative. We recognize the value of psychosocial rehabilitation and community integration models, and remain committed to working collaboratively with DMAS to ensure that the implementation of Mental Health Clubhouse Services enhances access to care while maintaining services quality, workforce stability and provider sustainability. However, we have several concerns regarding the structure and implementation of the proposed Clubhouse model and its potential impact on service delivery, ethical concerns, fiscal responsibility, workforce stability, and access to care. Additionally, the requirement to obtain and maintain Clubhouse International accreditation introduces both financial and operational challenges. We have reviewed all policy changes and have the following recommendations;

3.1 Clubhouse Staff Requirements:

The policy states a full-time Program Direction with the Clubhouse International training who holds a current, active, and unrestricted Virginia registration or license from the Department of Health Professions. *Recommend that the Program Director with QMHP be eligible to complete required assessments noted in Section 4.1. This will lessen the fiscal impact and allow programs to operate more cohesively with full-time Program Director responsible for overseeing operations to include admitting new members and ongoing authorization of services.

*The staffing and leadership requirements may present challenges for provider sustainability. The requirement for full-time Program Direction with specialized training, along with ongoing LMHP involvement introduces additional staffing costs. Given current workforce shortages, particularly among licensed professionals, these requirements may limit the number of providers able to successfully implement this model.

*The Services Definition and Critical Features is contradicted by the Provider Qualification Requirements and several burdens with Services Authorization, Documentation Requirements and Utilization Reviews outlined in the various sections of a very clinical approach to the Clubhouse International Model which is supposed to be a member driven, collaborative approach to rehabilitation services. 

3.3 Staff Training Requirements

The policy states all staff are required to receive training as required by Clubhouse International and all newly DMAS enrolled Clubhouses shall send a team to an authorized Clubhouse International training based within the first 12-18 months of operation, and staff are expected to participate in training or specialized tracks as a conditional of maintaining accreditation in good standing. *The required comprehensive clubhouse training and ongoing training to maintain accreditation is very costly- will funding or grants be made available? The suggested per diem rate of reimbursement does not support staff training requirements, please consider rate of reimbursement review.

3.4 Licensing and Enrollment Requirements

The policy states that providers shall submit with their DMAS enrollment application evidence of their initiation of the accreditation process or their formal accreditation with Clubhouse International. *However, if the service requires external accreditation for Clubhouse Internation, there should be consideration for alignment with DBHDS licensing requirements to reduce administration burden for annual review. 

3.6 Clubhouse Operation Requirements

The policy states the Clubhouse shall have an independent board of directors, or if affiliated with a sponsoring agency, shall have a separate advisory board comprised of individuals uniquely positioned to provide financial, legal, legislative, employment development, consumer and community support, and advocacy for the Clubhouse. *However, an independent board of directors requirement is a difficulty requirement for CSBs who have existing board of directors.  Recommend that you consider an advisory council comprised of program leadership and members.

4.2 Service Planning

The policy states at a minimum, the ISP shall be signed within 30 days of admission and 15 days of an ISP review by the Program Director or LMHP/LMHP-type performing the assessments. *The Clubhouse International Medel is not a clinical service therefore, recommend allowing the staff providing the service to sign it instead of the Program Director or LMHP.

5.1 Admission Criteria

Clubhouse International standards are very specific to membership in standards 1-7 so this section, as well as most others, are asking us to do additional requirements for DMAS on top of the already stringent CI standards and training. Membership is voluntary and part of the success of Clubhouse Internation is the members choice and active involvement in the community which does not involve criteria and assessment to become a part of, so this contradicts their standards and poses many ethical dilemmas for service providers.

7.1 Service Authorization Requirements

The policy states for both Preservice and Concurrent Authorization Requests that the DMAS form be completed along with initial assessment or addendum to the initial assessment and initial ISP or updated ISP, which again is an additional requirement than current PSR policy. *Recommend that DMAS waive the service authorization requirements due to additional training requirements and documentation demands. This is another burden for programs that are operating on minimal staff and increased member enrollment to ensure funding to support program operations. Services registration via MCP or Kepro portal should be sufficient for the change in level of care and additional expectations of providers for clubhouse services. If not willing to consider registration only for clubhouse, please consider revision to the service authorization request form to condense the process and allow for providers to submit the Comprehensive Needs Assessment, Treatment Plan and corresponding quarterly review in place of the DMAS authorization form for clubhouse services. Notable, all the information included in the CNA and ISP for new admissions is duplicated in the service authorization forms and just creates more documentation when current assessment and treatment plans meet criteria.

Section 8. Additional Documentation Requirements and Utilization Review

The proposed documentation and operational requirements represent a notable increase in administrative burden. The introduction of daily attendance logs, weekly progress notes, structured service planning timelines, supervision requirements, and ongoing accreditation processes will require significant administrative oversight. While accountability is important, these expectations may divert resources away from direct service delivery if not supported by appropriate reimbursement structures. 

8.3 LMHP Review

The policy states that an LMHP must review the documentation of all non-LMHP staff at least every 30 calendar days. *LMHPS currently provide assessment initially and every 6 months ongoing with progress notes and CNAs annually. Program Director or QMHP supervisor providing supervision should be sufficient for oversight of services provided at clubhouse to include review of documentation, specifically Program Direction who can be a QMHP per staff requirements and already doing monthly supervisions per 3.2 Staff Supervision Requirements and 3.1 Clubhouse Staff Requirements.

Furthermore, significant ethical concerns related to the double bind we are put in by being required to obtain a specific accreditation and then knowingly bill for the services which are directly in conflict of the standards of that accreditation. This is in relation to how the draft requirements do not align with clubhouse international standards however, we are expected to gain accreditation and uphold those clubhouse standards but not in their entirety per DMAS interpretation. Further ethical concerns are in regard to multiple psychosocial programs having already shuttered in anticipation of unaffordable transitions, leaving individuals in those areas without vital support. We fear this trend will continue unless meaningful changes are made, and we want to ensure DMAS understands the very real human impact of these regulations.

Thank you for allowing us the opportunity to offer recommendations and comments to this policy. 

3.1 Clubhouse Staff Requirements-

LMHP-R, LMHP-RP, or LMHP-S with Clubhouse International training — expanding eligible credential types and removing the "Clinical Director" title. Is the LMHP expected to be available on call 24/7? Is there flexibility between the program leadership and Director?

• Staff-to-member ratio changed: Old draft set ratio at 1:15; new draft raises it to 1:20 members during program hours. Ratio 1:20 is significant and poses a safety concern for emergency situations and day-to-day management. In addition, there should be a lesser ratio on community outings such as 1:10 ratio for safety in the community.

3.2 Staff Supervision Requirements (New Section)

• New section added requiring all Clubhouse staff to receive at least 1 hour of supervision per calendar month from the Program Director or LMHP. This is contradictory to the QMHP requirement to run the clubhouse. What is the training frequency after initial training?

3.3 Staff Training Requirements (New Section) This is a significant cost to CSB’s to transition to a new service that is extremely similar to current PSR services. Several CSB’s have already closed due to the anticipation that the costs of the transition are too great. This will have an impact on the PSR clubhouse population. It is highly likely that there will be an increase in decompensation and crisis situations as these members will no longer be receiving services or proper supports. It is also highly likely that there will be an increase in in-patient hospitalizations and incarcerations. Current daily costs for PSR services are $89.97 for 3 units and $59.98 for 2 units per day as opposed to the cost of a hospital emergency room visit and daily cost of a state hospital. An average emergency room visit is $520-$800 per day. Sometimes a mental health patient can stay in the emergency room for several days waiting for bed placement at a behavioral health unit. The average cost of an inpatient hospital stay is $1000 per day, with the average stay of 3-5 days. PSR services are evidenced based and have a demonstrated success rate to reduce the recidivism rate and inpatient hospital stays. I beg the argument that the costs of current PSR compared to emergency room visits and behavioral health units be considered and that the evidenced based practice of PSR services be reconsidered as an effective service.

• New section added requiring all staff to receive training as required by Clubhouse International. Will there be supplemental funding provided to support training? Is there a timeframe for when staff must be trained? Does everyone need to be trained or just the program director? How long is training good for?

• Newly enrolled Clubhouses must send a team (including at least one member) to an authorized Clubhouse International training base within the first 12–18 months of operation.  The newly proposed rate will not sustain the PSR program during the training process, nor will it cover the cost of training.

3.4 Licensing and Enrollment Requirements (Renumbered from 4.2)

If the service requires external accreditation for ‘clubhouse international”, there should be consideration for alignment with DBHDS licensing requirements to reduce administration burden for annual reviews.

? New draft: Application must be submitted within 18 months of DMAS enrollment; full accreditation within 3 years of DMAS enrollment. It has been stated that Clubhouse International is currently backlogged for years. How will they keep up with the demand of several new applicants?

• CARF exemption changed: New draft creates subsection 3.5.1 giving those providers an extended transition timeline (application within 36 months; full accreditation within 5 years), with a requirement to comply with all Clubhouse International Standards during the transition. Is there an option between Clubhouse international or CARF accreditation? If not, can CARF be reexamined as an option?

Governance/open meeting requirement made more specific: Old draft stated the Clubhouse "holds open forums." New draft requires meetings to be regularly scheduled, posted, and accessible, and that member participation in governance shall not be contingent on clinical status or participation level.

What holidays are accepted by the Clubhouse International model, please clarify.

An Independent board of directors’ requirement is a difficult requirement for CSB’s who have an existing board of directors. Please consider an advisory council comprised of program leadership and members.

Prior assessment acceptance added: New draft allows use of an assessment completed within 12 months prior to admission, updated in person, rather than always requiring a new full assessment — reducing administrative burden. What type of assessment needs to be completed? Does an assessment need to be conducted for each department and are they interchangeable among the different services within one CSB?

Service authorization sub-provision removed: Old draft required service authorization for any reassessment beyond the annual one; this was deleted. Is this stating that we just need one authorization from the MCO?

4.2 Service Planning

• ISP signing deadlines added: ISP must be signed within 30 days of admission and 15 days of an ISP review by both the member/legal representative and the Program Director or LMHP/LMHP-type. Consider staff completing the service plan and signing it rather than the Director/LMHP. If the clubhouse international model is not a clinical service, what is the rationale for an LHMP signature?

Crisis plan integration added: New draft requires all ISPs to incorporate a crisis plan per section 4.4. During the clubhouse international training process, will crisis training be provided considering QMHP’s are not clinical staff and do not have the proper credentials to mitigate in a crisis situation? Asking for QMHP’s to assess and intervene in cris situations appears to be an unethical practice.

5.1 Admission Criteria

In comparison research shows that PSR population differ from Clubhouse International population whereas CI clients are higher functioning and are more capable of vocational skills whereas PSR clients require an individualized recovery plan to reduce mental health symptoms, increase ADL skills, and restore skills.

The Clubhouse model thrives on a non-clinical environment, proving that clients are more capable of manging skills at a higher level.

 PSR offers a more structured, clinical, and goal oriented approach compared to clubhouse international. CI focuses on a voluntary community and work ordered day. PSR caters more to individuals needing more intensive skill building such as ADL’s and IADL’s therefore needing more clinical oversight. 

The skill levels should be considered before forcing PSR members into a new model that they may not be capable of performing within the parameters of a work ordered day.

Continued stay standard changed: Old draft required "objective behavioral/functional measurements of improvement." New draft recognizes that maintenance of skills, community integration, employment, social connections, or prevention of deterioration/higher-level-of-care utilization also justifies continued stay — reflecting the long-term nature of the Clubhouse model. Thank you for changing this standard.

Non-engagement discharge threshold established: New draft requires at least 120 days of nonattendance and at least three documented outreach attempts using varied modalities (phone, letter, peer outreach) before discharge for non-engagement. Old draft had no defined threshold. Current DMAS requirements state that an ISP be reviewed every 90 days. Changing the discharge requirement to 120 days will cause the ISP to be delayed and therefore out of compliance.

• Member choice of discharge added: New draft adds "the member chooses to discharge" as an explicit discharge criterion. Is this the only option for discharge?

• New general requirements subsection added (7.1): Includes a standard 6-calendar-month authorization timeframe, a provision allowing MCOs to waive SA if providers are within permissible limits and members are progressing, and the MCO/FFS contractor's ability to recommend alternative services. This is contradictory to section 4.1 Assessment section which states that the authorization period is every 6 months.

Minimum service requirement added (7.2.3): New draft requires a minimum of 24 consecutive months of service, with authorizations issued in 6-month increments. This concept was not present in the old draft. This section needs clarification. This appears to read that a client must that it is a requirement for a client to receive services for a minimum of 24 consecutive months.

• Member return rights added: New draft explicitly states the Clubhouse retains the right of all members to return after any absence without re-authorization or re-assessment, unless formally discharged per Section 5.3. If members were discharged then reassessment should be in order to determine if clints meet criteria regardless of whether they were a pervious member. There are sometimes stipulations that a client has to be discharged against their will non-compliance of behavioral guidelines and an inability to thrive in a clubhouse environment.

New draft — 8.2 Weekly Progress Note: A weekly narrative note replacing the daily narrative note, with required elements including an attendance table, narrative covering services, member engagement, behaviors, progress, and plan for the coming week. Notes may be co-written, collaboratively written, or drafted by the member — a significant change from the old draft's restriction that only the delivering staff could complete notes.

Is there a choice between daily logs or weekly notes or are both required? Is this suggesting that members write their own notes? Additionally, It is not feasible for the best use of time for an LMHP requirement to complete or sign off on clinical notes every 30 days for each member’s clinical documentation. This is not feasible or the best use of time for the LHMP skillset and contradictory for a non-clinical service. It appears that the documentation requirements for CI are excessive and do not adequately reflect the clinical level of service for reimbursement rate. Consider consolidation. 

H2031 per diem requirements restructured: Old draft required "a minimum of two required service components on the day of service, with at least one in-person." New draft requires RSB shall be provided in-person on each day billed, with documented exceptions permitted when at least two other service components are provided in-person, or when an initial or annual reassessment is the primary service on that day.

Rate does not support the accreditation, staff training, and construction costs requirements. Who is expected to become the funding source for members who want to continue who are not covered by Medicaid or are not authorized for the service but have Medicaid? The requested details for a concurrent authorization in the first 24 mos of services is overly burdensome. Consider consolidation of requirements to a specified form or inclusion of most recent ISP review instead during the first 4 continued stay requests.

Prince William County Community Services through its Ethics Committee, has reviewed the proposed Clubhouse Draft Policy and determined that it creates an unresolvable ethical and regulatory conflict for providers. The issue does not lie with the Clubhouse model itself, but with the requirement that providers obtain accreditation from Clubhouse International as a condition of Medicaid reimbursement.

Primary ethical concern:

As written, the policy establishes a regulatory double-bind: providers must simultaneously comply with all Clubhouse International standards for accreditation —which define the model as non-clinical—and Medicaid and state clinical requirements that mandate diagnosis-driven, medically necessary services delivered under licensed supervision. These requirements are structurally incompatible and cannot be reconciled through good-faith compliance.

This conflict forces providers into one of two untenable positions: either disclose required clinical practices and risk failing accreditation (and thus losing reimbursement), or conceal those practices to obtain accreditation, resulting in material misrepresentation to the accreditor, the clients we serve, and the public. Informal suggestions noted during DMAS office hours, indicating that standards may be applied flexibly do not resolve the issue, as providers must operate based on the formal, written requirements of two separate authorities with no guarantee of alignment.

The following conflicts are of detailed concern, and cannot be resolved through documentation adjustments or flexible interpretation:

Clinical role of staff: Clubhouse International literature (https://clubhouse-intl.org/what-we-do/what-clubhouses-do/) explicitly states that staff do not educate or treat members. DMAS Draft Manual Section 2 and DBHDS regulations (12VAC35-105-20) require interventions designed to treat the clinical needs of the client.  Staff cannot function effectively as non-clinical peers and supervised clinical providers simultaneously. This is the foundational incompatibility from which the other conflicts flow.

Risk, safety, and LMHP professional obligations: The Clubhouse model's non-treatment philosophy limits staff to non-clinical engagement. Virginia licensing law — specifically 18VAC115-20-130 (LPC) and 18VAC140-20-150 (LCSW) requires LMHPs to practice in a manner that protects public health and safety and to justify all services as clinically necessary. The non-clinical role structure does not eliminate these obligations. It undermines the clinical culture through which they are ordinarily exercised, eroding the clinical vigilance that is legally required of a practicing LMHP.

Confidentiality and HIPAA: Clubhouse International Standard 8 prohibits formal staff-only meetings where member issues are discussed. HIPAA and clinical risk management require exactly those meetings for complex and high-risk cases under LMHP oversight. Compliance with one framework means violation of the other. This is a direct contradiction between a statute meant for clinicians and an accreditation standard meant for non-clinical staff.

Professional liability consequences for LMHPs. Va. Code §8.01-581.20 establishes that the standard of care — the degree of skill practiced by a reasonably prudent practitioner in the same specialty — is not reduced by program design constraints an LMHP accepted as conditions of employment. An LMHP who limits their clinical role to comply with incompatible components of the Clubhouse model remains fully liable under this standard if foreseeable harm occurs. This places LMHPs in a position of unresolvable professional conflict: responsible for outcomes they are structurally prevented from influencing.

SUGGESTIONS TO CONSIDER:

We are not asking DMAS to abandon the Clubhouse model. We are asking DMAS to eliminate the specific accreditation requirement that generates the conflict, yet allow the tenants of the model to guide programming that meets the individual providers’ own population and cultural needs.

1.For providers with existing CARF Community Integration Accreditation: accept that credential as sufficient evidence of fidelity to the Clubhouse model's operational spirit. CARF accreditation, which is non-prescriptive, supports Clubhouses which value the work-ordered day, member-centered activities, and the community-integration framework without incorporating standards that conflict with clinical requirements. It does not create the double-bind. Virginia has already established precedent for accepting CARF accreditation as a qualifying credential in behavioral health services, and providers currently holding this accreditation have demonstrated sustained commitment to these core values.

2. For providers without existing CARF accreditation, and for jurisdictions where third-party accreditation costs are prohibitive: develop a DMAS attestation or state-administered fidelity review process based on the non-conflicting operational features of the Clubhouse model — the work-ordered day, meaningful member involvement, and the community integration framework. Virginia has direct precedent for this approach. The DARS IPS Supported Employment provider agreement explicitly permits providers to offer IPS services based on the achievement of good fidelity, in lieu of CARF accreditation (DARS Provider Agreement Appendix K, revised June 2024). DMAS and DBHDS administer ACT fidelity through the TMACT scale via Virginia Commonwealth University's Center for Evidence-Based Partnerships, without requiring external accreditation (DMAS Mental Health Services Manual, Appendix E). A parallel approach using the Clubhouse model's non-conflicting features would preserve the model's core intent while remaining compatible with the clinical structure Medicaid requires and would be accessible to providers for whom third-party accreditation costs are prohibitive.

We urge DMAS to resolve these conflicts before the policy is finalized and to engage directly with CSBs and providers who have identified them during the public comment period. We are prepared to participate constructively in that process.

Thank you for consideration of our comments and suggestions.

The CSB supports the inclusion of Clubhouse Services as part of the behavioral health continuum and appreciates the emphasis on recovery-oriented care.

Model Fidelity and Accreditation
Clubhouse programs must align with international standards emphasizing voluntary participation and community engagement. Accreditation timelines should be extended to 36 months to allow program development.

 Workforce and Capacity
Staffing models must reflect the non-clinical nature of Clubhouse services. Overly prescriptive requirements may limit scalability and reduce access.

 Caseload and Engagement Capacity
The Clubhouse model depends on meaningful member engagement. Excessive requirements may reduce staff availability and limit participation capacity.

 Coordination with Other Services
Clubhouse services should operate alongside clinical services when appropriate. Flexibility is essential.

 Crisis System Alignment
Clubhouse programs are not crisis providers. Requirements should not delay or interfere with referral to 988 or Mobile Crisis, as doing so may create safety risks.

 Documentation and Administrative Burden
Documentation requirements should reflect participation and recovery, not clinical treatment standards.

 Implementation and System Impact
Implementation will require coordination across systems, staff training, and EHR alignment. A 12–24 month phased rollout is recommended.

 Conclusion
The CSB recommends maintaining fidelity to the Clubhouse model, extending accreditation timelines, ensuring flexibility, and aligning policies with existing crisis systems to support safe and effective implementation.

Thank you for providing us with the opportunity to make comments and to seek clarification of the proposed Clubhouse model. The key themes of concern are centered around fiscal impact and administrative burden. The proposed plan for requiring Clubhouse International as the sole accreditation source has resulted in at least 3 Virginia PSR programs closing or with formal plans to close, while several more agencies have considered closing in the Virginia Leadership network. The consequence of PSR programs closing in the state is decreased access to valuable service and potential disruption in the recovery efforts of individuals who attended the programs that are now closed. The lack of access to care may contribute to the need for higher intensity services and a significant increase in cost to Medicaid.

We currently operate a psycho-social program that mimics a clubhouse program in many facets. Participants within our program obtain tangible outcomes that promote independent functioning and decrease the need for more intensive levels of service. The current draft eliminates the ability for programs to have other effective evidenced based practices like CBSST (Cognitive Behavioral Social Skills Training) integrated into psychosocial groups and IPS (Individual Placement and Support) within the same physical space, amongst others. Being 1 of 2 localities in the state who have achieved good fidelity to IPS, the integration of Clubhouse’s transitional employment within the same agency appears in conflict. We understand that there are ongoing conversations with IPS and Clubhouse regarding the two services working together, but that is not addressed in the current draft of regulations.

I am concerned that we will see more PSR/Clubhouse programs close because of this draft policy and the ultimate impact will be felt by the vulnerable clients we are trying to serve.  In the smaller rural areas where services and workforce resources are already limited, the ability to move to a highly expensive model, the increased administrative burden- especially documentation,  and clinical oversight for what will be considered a non clinical service is more than challenging; it presents a real threat to our existence.   I hope DMAS finds it possible to re-evaluate the entire draft policy.    

The proposed DMAS draft continues to highlight significant discrepancies between the regulatory framework and the standards required for certification by Clubhouse International. These discrepancies suggest that the proposed rules are more appropriately aligned with clinically driven service models rather than the clubhouse model, and therefore warrant clarification and expansion of allowable service model options.

While the clubhouse model is a well-established, recovery-oriented approach emphasizing member choice, peer support, and a work-ordered day, it is not inherently structured to meet the level of clinical specificity, medical necessity criteria, and staff-directed intervention requirements outlined in the proposed regulations. Attempting to impose these requirements onto clubhouse programs risks creating documentation and practice inconsistencies that could compromise both regulatory compliance and model fidelity.

Key Observations:

1. Alignment with a Clinical Framework
   The proposed regulations strongly reflect a medical and clinical model of care, including individualized treatment planning, staff-led interventions, and measurable, goal-oriented service delivery. These elements are foundational to clinical service models but are not naturally congruent with the clubhouse approach, which is intentionally non-clinical and member-directed.
2. Documentation and Medical Necessity Standards
   Requirements for detailed, intervention-specific documentation tied to clinical goals are consistent with therapeutic and rehabilitative service models. In contrast, clubhouse services are structured around participation and engagement rather than discrete, billable clinical interventions, making alignment challenging without fundamentally altering the model.
3. Service Delivery Expectations
   The emphasis on staff-to-client service provision, clinical oversight, and defined therapeutic interventions suggests that DMAS is conceptualizing psychosocial rehabilitation as a structured clinical service. This differs significantly from the clubhouse model’s emphasis on shared responsibility and non-hierarchical relationships.
4. Additionally, the client to staff ratio is concerning. The current draft indicates an increase to 1:20. Given the complexity and needs of the individuals served in PSR programs, lower staff to individual ratios are needed to ensure safety and quality of care, especially with the documentation requirements in the current draft.  

Financial and Ethical Considerations:

The current misalignment also raises important financial and ethical concerns:

• Requiring clubhouse programs to document services as individualized, staff-directed clinical interventions may inadvertently lead to documentation that does not accurately reflect the service delivered. 
• Forcing a non-clinical model to conform to clinical billing structures may result in administrative inefficiencies, increased overhead, and reduced time spent on meaningful member engagement. This undermines cost-effectiveness and may divert resources away from direct service delivery.
• Equity and Access Concerns
  If clubhouse programs are unable to comply with clinical requirements, they may reduce services or close, limiting access to recovery-oriented supports. Conversely, maintaining reimbursement for services that do not meet clinical intent may create inconsistency in service quality across providers.
• Ethical Tension in Service Representation
  There is an inherent ethical concern in requiring providers to frame member-driven, voluntary activities as clinician-directed interventions to meet billing standards. This may compromise transparency, professional integrity, and person-centered care principles.
• Program Integrity and Accountability
  Aligning reimbursement with clearly defined clinical models supports stronger accountability, clearer outcome measurement, and more defensible use of public funds.

Implications:

Given these discrepancies, it may not be appropriate to expect clubhouse programs to conform to the proposed regulatory structure. Instead, the regulations appear better suited to service models that are inherently clinical, intervention-based, and documentation-driven.

Recommendations:

1. Clarify Service Model Intent
   DMAS should explicitly define whether psychosocial rehabilitation services are intended to operate within a clinical framework. If so, regulations should acknowledge that this framework differs from the clubhouse model and may not be compatible with Clubhouse International certification standards.
2. Establish Distinct Service Tracks or Model Options
   Consider creating separate regulatory pathways, such as:
• A clinically oriented psychosocial rehabilitation model aligned with medical necessity and therapeutic interventions
• Reconsider allowing for CARF certification
• A clubhouse or recovery-based model with alternative documentation and service structure requirements
3. Recognize Clinically Aligned Evidence-Based Models
   Several established models are more consistent with the proposed DMAS framework, including:
• Psychiatric Rehabilitation (clinical PRS model) focused on skill-building, functional assessment, and individualized goals
• Cognitive Behavioral Therapy (CBT)-informed skills groups, which align with goal-oriented, measurable treatment interventions
• Illness Management and Recovery (IMR), which integrates recovery principles within a structured clinical framework

These models inherently support the types of documentation, service definitions, and staff roles described in the proposed regulations.

4. Ensure Regulatory-Model Fit
   Aligning regulations with clinically oriented models would reduce administrative burden, improve documentation integrity, strengthen ethical compliance, and ensure that services delivered are consistent with both regulatory expectations and evidence-based practices.

In summary, the proposed DMAS regulations appear to be thoughtfully designed for clinically structured psychosocial rehabilitation services. However, they are not well aligned with the clubhouse model as defined by Clubhouse International. Rather than attempting to adapt clubhouse programs to fit a clinical framework, it would be more effective to either (1) establish distinct regulatory pathways or (2) prioritize models that are inherently compatible with the clinical expectations outlined.

Thank you for your consideration and for the opportunity to provide input on these important regulations.