The petitioner requests that the Board amend 12VAC35-105-1840(C)(3) to allow crisis stabilization units to base nursing coverage on an individualized services plan (ISP)-driven, two-tier nursing model.

According to petitioner: 

This amendment will align DBHDS regulations with DMAS standards, which base nursing coverage on the initial nursing assessment and ISP, and will help ensure that crisis stabilization services remain both safe and financially sustainable across the Commonwealth.

Nursing Requirement & Financial Impact Analysis

Under the DMAS Comprehensive Crisis Services Manual (Appendix G), crisis stabilization units must provide in-person nursing services 24 hours a day, seven days a week when required by the initial nursing assessment and individualized service plan (ISP). However, a detailed financial review demonstrates that meeting this standard for every client—regardless of actual clinical need—creates unavoidable deficits when all required professionals are considered.

A registered nurse (RN) or licensed practical nurse (LPN) paid between $35 and $40 per hour costs about $840 to $960 per day, or $4,200 to $4,800 over a five-day stay. In addition, a Qualified Mental Health Professional (QMHP) at roughly $20 per hour adds about $160 per day ($800 per five days); a Certified Substance Abuse Counselor (CSAC) at $25 per hour adds $200 per day ($1,000 per five days); and a Licensed Mental Health Professional (LMHP) at $30 per hour adds $240 per day ($1,200 per five days). Together, these staff drive a combined direct cost of roughly $1,440 per day—or $7,200 over five days—before any employer burden such as payroll taxes, overtime differentials, benefits, workers’ compensation, or professional liability insurance is applied.

When compared with the fixed DMAS reimbursement of $847.04 per day (about $4,235 for five days), even the most conservative scenario falls short. For example, an RN at $30 per hour yields a narrow daily surplus of about $127 before fringe costs. But at more realistic market wages—around $40 per hour, in line with Bureau of Labor Statistics data—the nursing expense alone creates a daily loss of more than $112, or about $41,230 annually per client. Once the required QMHP, CSAC, and LMHP staffing is included, the gap widens dramatically. With modest employer overhead (≈30 % for taxes, benefits, and insurance), the daily cost climbs toward $1,875, producing a loss of over $1,000 per day, or $5,000 for each five-day admission.

This analysis confirms three critical points. First, the true breakeven wage for 24/7 nursing is approximately $35.29 per hour, and even at that rate, sustainability disappears when employer costs and additional staff are added. Second, the DMAS reimbursement structure cannot absorb market-based wages and required professional coverage. Third, aligning staffing with the results of the initial nursing assessment and each client’s ISP, as DMAS already permits, is the only way to preserve both safety and financial viability.

In summary, when all required professionals—RN/LPN, QMHP, CSAC, and LMHP—are included, the actual cost of a single five-day crisis stabilization stay far exceeds DMAS reimbursement. Without regulatory flexibility to implement an ISP-driven, two-tier nursing model, providers face unavoidable and continuing losses, placing essential crisis services and timely access to care at risk throughout the Commonwealth.

The petition for rulemaking will be published in the Virginia Register of Regulations on October 20, 2025. The petition will also be posted on the Virginia Regulatory Town Hall at www.townhall.virginia.gov to receive public comment. The public comment period will open on October 20, 2025, and close on November 10, 2025.

The Board will consider the petition and all comments at its next regular meeting, currently scheduled for December 10, 2025. The petitioner will be notified of the Board’s decision no later than 14 days after that meeting. 

At its meeting on December 10, 2025, the State Board of Behavioral Health and Developmental Services voted to take no action on the petition because 12VAC35-105-1840 is already aligned with Medicaid standards. DBHDS licensing regulations are not more stringent than DMAS policy for crisis services nursing coverage. 

DMAS staffing ratios are not tied to nursing assessments or ISPs; rather, Medicaid standards as reflected in Appendix G mandate 24/7 in-person, onsite nursing coverage at all times in RCSUs. DBHDS coordinated with DMAS when developing the regulatory text and staff confirmed the current requirement in 12VAC35-105-1840 is in alignment. Therefore, granting the petitioner’s request would place DBHDS Licensing Regulations out of alignment and reduce consistency for providers.