33 comments
Hello,
My name is Bob Larkin. I am the Training Coordinator at Richmond Residential Services. I have been using and training the DBHDS DSP Orientation and Competencies since their implementation. I have reviewed the newly edited version of the Basic Competencies and wish to comment on them.
First, I do want to commend you on realizing that the original tool was enormous and a bit confusing. Competency- based supervision is something that I do support. However , in the current environment of our work in Virginia dictates that we are very often hiring inexperienced workers that will accept the hard work and little pay. At RRSI, we do an excellent job with new employee orientation, program specific training, health training, and crisis intervention including behavior observation and management. It has been an overly ambitious requirement to expect a novice employee will become a competent professional in one year. I fear that with DBHDS now expecting this to be achieved in 180 days agencies will simply not be able to utilize person-centered techniques and strategies to meet employees where their needs are and will lose many employees who might have had great potential to serve our individuals. I have researched how NADSP Code of Ethics and Core Competencies are being addressed in states like New York and I would urge the Commonwealth to mirror their blueprint to achieve the desired outcomes. It seems New York acknowledges that Competency-based supervision is more of an evolution for employees and not something that can be dictated nor punitive. . If I understand the new DBHDS requirements of not allowing professionals to work alone until they are competent in Competency 3 will simply not be conducive with the current reimbursement structure under the Medicaid Waiver. At RRSI we follow DBHDS regulations and will continue to do so. However as our industry faces stagnant rates, low pay, and a workforce that often needs to hold two to three jobs to make a living, planning to cover programs under the proposed requirement will force many agencies to close or not be forthcoming on their developing workforce.
My agency has struggled to achieve full competence in the supplemental competencies: Autism, Behavior, and Health. I do acknowledge that for individuals requiring more intense supports that professionals will need additional knowledge and experience, however since DBHDS does an excellent job of pushing person-centered treatment, our workforce learns what they need to support the individuals in their care. They work with experienced supervisors, directors, quality assurance, and training within their agencies and will community partners such as Behavior specialist and Health care professionals. The new expectation that training in these supplemental requires the hiring or purchasing of training offered by professionals such as Registered nurses, Psychiatrists, and Board certified professionals is an impossible expectation for any non-profit agency who have not seen a Medicaid waiver rate increase in over five years. I would think a better solution would be to make sure the training curriculum utilized by an agency met your DBHDS standards.
It appears there is come inconsistency in the requirements for the supplemental ratings. On page 8 of the protocol document it states that Basic competencies are for SIS tiers One through Four. However it later states several times that the additional competencies have to be achieved when supporting individuals at Tier Four (page 9)
As to the tool itself, I suggest some edits to clean up the tool. There are breaks in odd places and the borders do not always line up.
I would be happy to support appropriate changes to the proposed document and to create a helpful plan to implement and monitor progress.
DSP competencies should include recognizing signs of abuse/neglect, and the responsibility for reporting Abuse and Neglect to proper authority, and the legal requirement for reporting.
I do not understand the reason for retaking the orientation test as an accurate measure when someone is found not competent. Most staff are able to reach the 80% (in fact I have never had someone get lower than a 90%) as it is a knowledge based test. The competencies are action based, and just because staff knows the answer to a question, does not mean they use that knowledge correctly in real time.
I also would like to address the issue about a staff not being able to work provide any services should they not be found fully competent initially. We were told that if a staff is found not competent, and they have worked with individuals, we would have to pay back all revenues for the time the staff worked. As someone brought up in the roundtable meeting, this is a catch 22, especially for sponsor. You can't know if a staff is competent when they cannot work with the individual, especially as the competencies are individualized to that person. Also, it is cost prohibitive for the smaller organizations.
First of all, I like the new format and that it has streamlined in order to be user friendly and efficient. The major problem that I see in this upgrade is the demanding of proficiency with in 180 days. The job market is currently an employee job market. Making it difficult to hire experienced staff for the rate of pay which we have to offer, and inexperienced staff take longer than 180 days to become proficient in this field. Another barrier to hiring experienced staff is our rural location. This was mentioned in another comment and I agree fully with his logic. DBHDS does not need to make getting and keeping good staff any more difficult than it already is. We are very proficient in training new staff but staff's ability to completely implement the skills being taught within the 180 days and using person-centered thinking is nearly impossible. As stated in the other comment please look at New York's model and help providers keep potential good employees. Thank You
Consideration #1 Under the heading Defining Direct Support Professional (DSP): “This term (DSP) shall exclude consumer-directed staff and services facilitation providers.
Consumer Direct (CD) services include Personal Assistance, Respite, and Companion services.
Personal Assistance, Respite, and Companion services can also be Agency directed.
The reimbursement rates for CD AND agency directed Personal Assistance, Respite, and Companion are the same, yet, DMAS is holding a higher standard of training and competency verification creating an administrative burden on agencies for the same reimbursement rate as CD services.
Solution 1 – Require the same level of training and competence for CD services as is for agency directed services, or raise the reimbursement rate for agency directed services to match the administrative financial and resource burden.
Solution 2 – Provide, free of charge, web based training and competency testing to Agency and CD services staff.
Consideration #2 Supplemental / least restrictive services for both children and adults is a stated goal and expectation yet is underrepresented with greater a expectation of compliance than CD services for similar supports.
According to the most recent independent reviewer report, it has been noted
“…by the Independent Reviewer highlighted system-wide problems that the Commonwealth has not yet adequately addressed. The Commonwealth does not have either a sufficient quantity or the needed geographic distribution of the most integrated community-based residential services options. It also does not have enough services providers to support individuals in these options, especially the members of the target population with particular needs. These individuals include adults … and children…who need and are able to live in settings that provide more independence and in their own home with more integrated daily lives…”
The expansion of least restrictive services is hindered by failure to acknowledge agencies willing and able to do the work and expand services but are silenced by administrative and financial burdens that focus on trainings that are not shared with Consumer Directed Services. Furthermore, the DSP Orientation manual focuses solely on 24 hour residential services provided to adults. IE supplemental services is given a nod on slide 15 as a goal (moving persons from a service life to a community life) within the orientation yet children services are omitted both in the training and on the test. Again, I will point out that the DSP Orientation training is not required for CD services offering the same level of supports to ID/DD persons meeting the same criteria as those receiving the same agency directed supports for the same reimbursement.
Solution #1 – include supplemental services and supports of children in the DSP orientation.
Solution #2 – look at the system that places additional burdens who are ready and willing to provide least restrictive services and adjust the financial burden and expectations accordingly.
Solution #3 - DMAS provides the expected training through an online learning environment so that the intended information is properly communicated. From there, supervisors can confirm through their ongoing observation if the DSP continues to meet proficiency
Consideration #3 - Competency and proficiency is fluid. A person can be determined competent and proficient in one setting but lack the same in another. Making the portability of the competencies less than person centered. Furthermore, one can pass a test and have the appearance, though observation, that staff are proficient. However, passing a test, having received training and observing compliance does not preempt criminal, amoral, or unethical behavior. I understand the purpose of competencies and have no qualms with using tools to guide training and supervision efforts. However, licensing requirements for training and supervision already exists and should be enforced.
Solution #1 - enforce regulation and law already in place rather than creating overlap where none may in fact be needed.
Solution #2 - prohibit portability of DSP Orientation and Competencies to limit opportunities to reemploy staff who were dismissed due to failure to meet job requirements and to limit opportunities for staff to "job hop" once their competencies and training requirements were met.
In the “Orientation and Competencies Protocols” we are requesting that the Positive Behavior Support Facilitator (PBSF) should be included as an Autism Professional, the same as they are in the Behavior Professional.
I wanted to clarify the information regarding the comparison of the rates between agency and CD services.
The reimbursement for PA, respite and companion alone is $9.40. There are several other services embedded in the CD that raise the average reimbursement to anywhere between $13.50 and $14.50 per hour billed. These services are tied to Service Facilitator billing that includes Routine visits, employee management training / consumer training, Individual and family caregiver training, CD management training and reassessment visits.
Town Hall comments/response to the
DSP and DSP Supervisor DD Waiver Orientation and Competencies Protocol.
Since the “Agency Director or designee” is completing the proficiency document and observations on the Supervisor; are there training requirements for the Director or designee? Are they expected to complete the Supervisor’s assurance test on the VLC website?
Who qualifies as an “approved and qualified trainer” for training DSPs and Supervisors who work with individuals who are a tier 1-3? What qualifications are needed?
Can a supervisor delegate the observations of DSPs performing certain tasks outlined in the checklist? Or do they have to observe all?
On page 7, the guidance indicates “Confirmation of training” must be maintained. Are dates and a description of the training sufficient? Or are certificates required?
The explanation of when services are billable (in the box on page 7) is confusing. One paragraph seems to say that a program can bill if the DSP is competent, but the last paragraph seems to indicate that billing cannot take place unless the DSP is proficient.
Also on page 7, is there a grace period for DSP to become proficient beyond the 180 days?
For an individual who is identified as a tier 4, more clarification is needed on which of the extra competencies are needed. It seems that the document (see page 8) is stating that all three extra checklists have to be completed for anyone who is a tier 4. It may be reasonable to say: The autism competency checklist should only be completed when the individual has a diagnosis of autism. The health competency checklist would only be completed when the SIS indicates exceptional medical needs. The behavior competency would only be completed when the SIS indicates exceptional behavior needs.
On the actual checklist, please consider moving health and wellness the first category instead of the third, as it is most important.
In the Medicaid Memo of 1 September 2017, the following caveat, in bold typeface below, was added to the requirement for when “advanced competencies” are required. This approach of recognizing training specific to the needs of the individual was carried forward into the several drafts of the proposed regulations which have circulated for comment.
“Training and competencies must be initiated by the provider upon notification of the individual’s assignment to level 5, 6 or 7 or the approval of the customized rate and completed within 180 days if the provider cannot show that comparable training specific to the needs of the individual has not already been completed.” Medicaid Memo – 1 September, 2017
In addition to the unreasonable administrative burden that completing mostly irrelevant training and checklists imposes, the specific needs of an individual which may prompt an assignment to a higher level can rarely wait up to 180 days to be addressed and the training/skill set needed for any staff must be addressed when the need is identified not when a SIS is updated!
Core Competencies
We will not analyze in detail the proposed revision of the Competency Checklist – it continues to be cumbersome and difficult to use. However, we continue to have difficulty with the concept of “competency” being insufficient as a minimum standard for staff. It is particularly troublesome when you consider that the proposed system requires that someone be “competent” to provide services, but being “competent” is not sufficient to provide services after 180 days. What you have done is make “proficient” the lowest common denominator or the minimum standard for staff. The definition of “proficient” as either “when the skills are observed over time” or “an ongoing level of ability that is above the minimum” only means that one is “competent” on a more or less consistent basis. That is what we expect of all staff, but we are not doing our jobs if we don’t identify and remediate when someone is falling short.
Nothing in the protocol ties the use of this tool to the provider’s internal systems which review and document performance. We think this should at least be mentioned, and providers should be encouraged to integrate the processes. Provider’s should also be encouraged to do a preliminary scan 60 to 90 days before the annual reprise of the checklist to identify any areas which may require some remediation.
We will address specifically the items in Competency Level 3 in which an individual must be determined “competent” before they are permitted to work with the individuals who we support. While I appreciate the intent, I believe that you will find the vast majority of the items either marked N/A and training will be provided as circumstances arise.
The challenge, of course, is that by implication the staff may not complete documentation (though required by 3.6) which would support billing until this form has been completed and signed. Even when working with more experienced staff, it is expected that part of the duties would be to complete required documentation for “assigned” individuals – clearly also something that is a skill to be learned. This is a conflict which needs to be resolved.
Specifically, I would replace item 3.7 with item 1.5 – it is far more relevant to setting the proper course for a new staff member. I would also rephrase any item which suggests that staff have “memorized” details which should be readily available in the record, e.g.; “identified health and behavioral support needs.”
While we clearly understand that DMAS should not reimburse for services that are not competently provided, the structure proposed will not solve the problem. If you remove the possibility of having a second 180 days (if staff are not completely proficient) in order to comply with the DMAS decision, then you must equally determine how to handle the annual reprise of the checklist.
Advance Competencies for DSP on page 8 of 11, it states if the individual has a SIS tier four to complete training in the areas of autism, complete health supports, and complex behavioral supports. Is the autism training required for individuals not diagnosed on the autism spectrum?
With regards to the change: "Competency 3 and all related skills must be confirmed competent prior to providing support in the absence of paid staff who has demonstrated proficiency with this competency." - page 7
1. 3.2 - Provides medication as prescribed - DSPs at SSVA do not receive medication training prior to working alone. SSVA offers medication training quarterly and enrolls employees in this training based on hire date and recommendation from supervisors (slots are limited). Because of the high cost of medication certification and high turnover rates in the field, it is not reasonable to expect employers to put DSPs through medication training before working alone. SSVA coordinates med certified staff to cover medication needs of individuals supported in instances where staff who are not yet med certified are scheduled.
2. Tracking completion of lengthy competency checklists is cumbersome enough with the requirement of 180 days and every year thereafter for every employee and sponsor. To add an extra tracking date of before working alone and then every year after adds another level to already overburdened administration system.
3. All DSPs must be certified in CPR / First Aid and Infection Control and DSPO prior to working alone. The majority of the items covered in part 3 of the competency checklist are covered in these trainings.
Autism professionals who can approve training for additional autism competencies should also include PBSF - Positive Behavioral Support Facilitators - who receive extensive training in Autism Spectrum Disorders. In their role, the PBSFs conduct functional assessments, create positive behavioral support plans, and provide training to people who support people with diagnosis of autism. SSVA currently employs a PBSF with over 30 years of experience in the field and who is considered one of the regional experts in the field to provide this training.
1. It is strongly recommended DBHDS streamline DSP competencies as most agencies already have competencies which are reviewed annually via Performance Evaluations, as well as mandated and other trainings that are competency based.
2. It is strongly recommended DBHDS consider not requiring Competencies for agencies that are CARF accredited who have not received recommendations in Workforce Development standards regarding training. CARF accreditation shows commitment to quality and competency.
3. On page 3 of “Direct Support Professional (DSP) and DSP Supervisor DD Waiver Orientation and Competencies Protocol”, lists Workplace Assistance Training as being a service that requires competencies. As Group Supported Employment does not require competencies and this would be a service provided to an individual receiving individual supported employment, in an integrated community employment setting, should this service be removed from the list?
4. On page 8 of “Direct Support Professional (DSP) and DSP Supervisor DD Waiver Orientation and Competencies Protocol”, those individuals having been assessed for a Tier 4 via the SIS require staff to complete training the areas of autism, complex health supports, and complex behavioral supports. Agencies utilizing MANDT training cover autism and complex behavioral supports – could this be considered to meet competency requirements? Each individual served on a tier typically does have specific trainings that are person-centered, provided to their staff, and documented via their plan.
5. If staff have already been deemed competent, unless there is noted regression we suggest, not having to continue to assess annually. Performance evaluations should already indicate competency.
6. On page 12, “Direct Support Professional (DSP) and DSP Supervisor DD Waiver Orientation and Competencies Protocol”, if an individual changes their SIS tier score to a higher tier, could the review of competencies be amended and specific to those individual’s needs, as opposed to completing the entirety of the competency assessment?
Page 7 – Competency 3 and all related skills must be confirmed as competent prior to providing support in the absence of paid staff who has demonstrated proficiency with this competency. – This will negatively impact Group Home, Community Coaching, Community Engagement and In-Home as the DSP’s cannot provide billable services alone prior to competency. These service lines do not fund adequately based on two staff providing the service. We cannot maintain fiscal viability to hire, train and provide each new hire with a second staff member or supervisor for all shifts until the employee gains competency; however, we provide drop in support from supervisors with new hires as well as support through our on-call system when needed. While we agree that there would need to be a competent DSP or Supervisor available during critical times until competency is established, we should not be required to provide the two staff at all times. We also continue to have a DSP shortage crisis across the state which would add another layer of difficulty with having enough people to maintain this requirement.
COMMENTS – vaACCSES
November 12, 2019
DBHDS Staff & Staff Supervisory Competency Protocols/Check-List
The process has been improved but further improvement is needed.
Suggestions for Further Improvement and Recommended Changes:
OVERALL COMMENT:
DEFINING DIRECT SUPPORT PROFESSIONAL (DSP)
Thank you for excluding professional staff of CARF accredited providers of Group and Individual Supported Employment services.
COMMENT: Exclude Benefits Counseling from DSP Definition & Level 1 Requirements - Certified Social Security Administration Community Work Incentive Coordinators (CWICs) and certified DARS Work Incentive Specialist Advocates (WISAs) should also be excluded from the definition of DSP and not required to complete the Level 1 Orientation Training and Testing as they are highly certified professionals that provide financial and benefits counseling not direct support. CWICs are further required to take 18 hours of annual continuing education courses specific to their certification. The Benefits Planning and Assistance Counseling service is not a service that is waiver or disability specific.
OVERALL COMMENT – CHECK-LIST - COMPETENT AND PROFICIENT
The ongoing issue regarding the competency checklist is that the level of skill, expertise and receptive ability that a DSP who may have just a high school diploma) is required to have prior to being able to provide care without the support of a proficient DSP present is arguably equivalent to that of a 2nd year college student. (the provider cannot bill without a "proficient" DSP present). These competencies are written from the perspective of highly educated people who assume that high school graduates will have the same academic capacity as they do to memorize, absorb and implement intense information. The educability of caregivers willing and available to do this type of work is generally limited to include those with no advanced education or training experience.
Additionally, many individuals receiving services do not utilize enough hours to fulfill a 40-hour work week for the DSP. Therefore, DSP’s will likely have more than one individual with which they work. To maintain proficiency for 2, 3 or more individuals is difficult. Group homes have as many as 6 individuals that the DSP may be responsible for. Many DSP’s work additional jobs and have families to care for as well. The provider then, must staff the individual with 2 DSP’s – one who is proficient and one who is trying to achieve proficiency. In a group setting, it is more likely to be possible to have the ability to financially support this intensity of training. But it is simply not feasible for providers that provide 1:1 service to do this under the current reimbursement rates.
COMMENT:
Issue #1: It is unrealistic to believe that learning about all the needs and wants of individuals can be done as a sprint when it is more like a half marathon. Even licensed medical professionals do not immediately know all the care needs of a new patient. They start with basic information and learn the specific details over time.
RECOMMEND: that the language be changed to allow for the “competent” level (vs. proficient) to be acceptable for a DSP to begin providing billable services. The definition of “competent” states “The individual demonstrates all of the skills or actions in column two, but not on a routine basis as appropriate to the skill or action; low level of supervision needed. Competency refers to the bare minimum required for acceptability.”
RECOMMEND: The last sentence states: “competency refers to the bare minimum…”. This should be completely omitted or rephrased to say “Competency refers to the minimum requirements for acceptability”.
Issue #2: There is nothing within the checklist that measures someone's ability to know what human rights violations are or how they are to be reported. We recommend to include under Section 3.
CHECK-LIST:
Page 5 of 8 for DMAS #P241a - Competency 3
COMMENT: Reconsider having two supervisory signatures. The smaller programs and some group homes only have one supervisory level person assessing competencies and providing the training needed to reach proficiency. In some cases, there may not be a second person available to observe and assess proficiency. In Day Programs, this is an additional administrative burden for which we were not previously required and will add administrative costs. If we trust supervisory personnel to assess proficiency in other areas, this should be sufficient in this area of the competencies.
COMMENT: Consider revising the competencies for Medical, Autism and Behavior (Forms DMAS #P201, DMAS #P244a and DMAS #P240a) – to streamline these competencies.
COMMENT: There is a concern about the required training for the Medical, Autism and Behavior competencies. There are not many certified training programs out there and those that are - have a cost to them. Most providers do not have access to the professional lists who must sign off on the in-house developed training indicated. This is another disincentive to providing services to those with higher needs.
OVERALL COMMENT:
There are three sections that should be considered optional and not be required for all DSPs or even all supervisors. In these examples of specific job duties, we contend that these requirements would NOT necessarily apply to all staff but might rather be reserved (and specified in job descriptions) to only staff who are assigned to provide these specialized supports:
3.2 “Locates medications and side effect information for all individuals supported, provides safe and accurate delivery of medication; reports unusual reactions, responses and behavior to the appropriate health professional immediately”
COMMENT: While the last phrase of that competency (reporting unusual reactions) applies to all staff, there are some staff who never deliver medications so the initial phrases about locating medications and side effect information as well as the actual delivery of medications should NOT pertain to all DSPs and supervisors.
3.3 “Correctly follows nutrition plans and meal preparation guidelines including the use of thickeners, special textured food preparation such as pureed and chopped consistencies and uses the correct utensils for all individuals supported”.
COMMENT: We again propose that not all DSPs and supervisors support individuals requiring this level of support. Even with the number of individuals discharged from Training Centers, these specific meal preparation guidelines are limited in applicability and providers should be able to identify (by job descriptions) which DSPs have both this support delivery (and therefore competency) requirement.
3.4 “Operates and maintains adaptive, orthopedic, and communicative equipment correctly” – COMMENT: Same comment as above: These competencies are essential when needed in specific job descriptions but should not be a requirement for all DSPs and supervisors.
In review of the updated competency checklist for DBHDS Licensed Providers that has been sent out for public comment, I take a minute to pause and really think about the true intention of this checklist. In review of the independent reviewer’s most recent report and prior reports, the following within section V.H.1 of the report is noted; “The Commonwealth shall have a statewide core competency-based training curriculum for all staff who provide services under this Agreement. The training shall include person-centered practices, community integration and self-determination awareness, and required elements of service training.”
I know that the increased competency requirements that Providers have witnessed throughout the state is a direct result of the outlined requirement that the state must uphold; however the way in which this can be tackled is not felt to be through the completion of checklists.
Additionally, the new guidance material indicates that the 8 page document would require additional processing in the amount of two or more times through each DSPs personnel file, as the Competency 3 section is required prior to service delivery in the absence of a proficient staff person, which would indicate that this checklist must first have section 3 completed and verified and sections 1 and 2 completed within 180 days with proficiency noted during that time frame as well. This appears to be a focus away from service delivery and more on the completion of a checklist, that may or may not accurately outline the skills of the noted staff, due to the implications that are present if this form is not present or not completed as it is should be.
We as Provider Agencies are open to meeting all requirements; however in working directly with the current system, it appears to be a consensus that changes are needed, as the way in which additional checklists and requirements continue the end result is not aligning with the outlined goal.
1) There are many skills under Competency 3 that could be N/A for some DSPs. Does the use of N/A apply to Competency 3 (specifically 3.2, 3.3, and 3.5) if a skill is N/A for a particular DSP in a Day Support program? There is a statement that “competency 3 and all related skills must be confirmed as competent prior to providing support in the absence of paid support who…..”
*Suggestion: add a statement that the use of N/A is permitted in all sections of the checklist or in the note under competency 3, state that the use of N/A is permitted.
3.2 – the observation (indicators) – this area needs clarification because if the DSP is not medication certified, then it would be marked N/A. However, the DSP should be able to describe the process for reporting unusual health events according to agency procedures.
2) 2.3 – it needs to be clear that DSPs can document alongside another DSP deemed proficient, and providers can bill for services even if the DSP is not proficient yet.
There is a documentation issue and conflict – It’s implied that Providers cannot bill for services until the DSP providing services is found proficient and until this form has been completed and signed, yet documentation is needed to bill. In order to determine if the new DSP is proficient, they must demonstrate they are proficient with documenting services provided with the required elements. This would be difficult to determine unless the DSP is documenting actual services provided. This needs to be addressed.
Thank you
DSP Competencies Comments
1. It is strongly recommended DBHDS streamline DSP competencies as most agencies already have competencies which are reviewed annually via Performance Evaluations, as well as mandated and other trainings that are competency based.
2. It is strongly recommended DBHDS consider not requiring Competencies for agencies that are CARF accredited who have not received recommendations in Workforce Development standards regarding training. CARF accreditation shows commitment to quality and competency.
3. On page 3 of “Direct Support Professional (DSP) and DSP Supervisor DD Waiver Orientation and Competencies Protocol”, lists Workplace Assistance Training as being a service that requires competencies. As Group Supported Employment does not require competencies and this would be a service provided to an individual receiving individual supported employment, in an integrated community employment setting, should this service be removed from the list?
4. On page 8 of “Direct Support Professional (DSP) and DSP Supervisor DD Waiver Orientation and Competencies Protocol”, those individuals having been assessed for a Tier 4 via the SIS require staff to complete training the areas of autism, complex health supports, and complex behavioral supports. Agencies utilizing MANDT training cover autism and complex behavioral supports – could this be considered to meet competency requirements? Each individual served on a tier typically does have specific trainings that are person-centered, provided to their staff, and documented via their plan.
5. If staff have already been deemed competent, unless there is noted regression we suggest, not having to continue to assess annually. Performance evaluations should already indicate competency.
6. On page 12, “Direct Support Professional (DSP) and DSP Supervisor DD Waiver Orientation and Competencies Protocol”, if an individual changes their SIS tier score to a higher tier, could the review of competencies be amended and specific to those individual’s needs, as opposed to completing the entirety of the competency assessment?
The new version of the checklist is shorter and more concise (and no important subject matter was lost in condensing into this revision). As an example, according to our member organization that piloted the revised process, had spent almost three days in 2018 reviewing and completing the previous version of competencies while this new draft version was completed by the group in 2019 within three hours.
A specific improvement is the “Observation (example indicators)” column included in the new draft checklist. This helped those piloting the checklist to ensure that they were interpreting the competency correctly and consequently sped up the process since it eliminated the need to brainstorm when and how each competency was demonstrated.
Suggestions for Further Improvement and Recommended Changes:
OVERALL COMMENT:
An electronic version would be more useful for several reasons, including:
The physical space for comments varies in the new paper draft version. There are times when we piloted it that we wanted more space and there were other times when we needed less. An electronic version would allow expansion of space only when needed, resulting in an efficient final document.
This new draft has unfortunately NOT reduced the voluminous requirement of initialing and dating by the supervisor in each section, along with signatures at the end. We propose that electronic signatures at the end of the checklist document would be sufficient and we could eliminate the requirement for initials and dates in each section.
DEFINING DIRECT SUPPORT PROFESSIONAL (DSP)
Thank you for excluding professional staff of CARF accredited providers of Group and Individual Supported Employment services.
COMMENT: Exclude Benefits Counseling from DSP Definition & Level 1 Requirements - Certified Social Security Administration Community Work Incentive Coordinators (CWICs) and certified DARS Work Incentive Specialist Advocates (WISAs) should also be excluded from the definition of DSP and not required to complete the Level 1 Orientation Training and Testing as they are highly certified professionals that provide financial and benefits counseling not direct support. CWICs are further required to take 18 hours of annual continuing education courses specific to their certification. The Benefits Planning and Assistance Counseling service is not a service that is waiver or disability specific.
OVERALL COMMENT – CHECK-LIST - COMPETENT AND PROFICIENT
The ongoing issue regarding the competency checklist is that the level of skill, expertise and receptive ability that a DSP who may have just a high school diploma) is required to have prior to being able to provide care without the support of a proficient DSP present is arguably equivalent to that of a 2nd year college student. (the provider cannot bill without a "proficient" DSP present). These competencies are written from the perspective of highly educated people who assume that high school graduates will have the same academic capacity as they do to memorize, absorb and implement intense information. The educability of caregivers willing and available to do this type of work is generally limited to include those with no advanced education or training experience.
Additionally, many individuals receiving services do not utilize enough hours to fulfill a 40-hour work week for the DSP. Therefore, DSP’s will likely have more than one individual with which they work. To maintain proficiency for 2, 3 or more individuals is difficult. Group homes have as many as 6 individuals that the DSP may be responsible for. Many DSP’s work additional jobs and have families to care for as well. The provider then, must staff the individual with 2 DSP’s – one who is proficient and one who is trying to achieve proficiency. In a group setting, it is more likely to be possible to have the ability to financially support this intensity of training. But it is simply not feasible for providers that provide 1:1 service to do this under the current reimbursement rates.
COMMENT:
Issue #1: It is unrealistic to believe that learning about all the needs and wants of individuals can be done as a sprint when it is more like a half marathon. Even licensed medical professionals do not immediately know all the care needs of a new patient. They start with basic information and learn the specific details over time.
RECOMMEND: that the language be changed to allow for the “competent” level (vs. proficient) to be acceptable for a DSP to begin providing billable services. The definition of “competent” states “The individual demonstrates all of the skills or actions in column two, but not on a routine basis as appropriate to the skill or action; low level of supervision needed. Competency refers to the bare minimum required for acceptability.”
RECOMMEND: The last sentence states: “competency refers to the bare minimum…”. This should be completely omitted or rephrased to say “Competency refers to the minimum requirements for acceptability”.
Issue #2: There is nothing within the checklist that measures someone's ability to know what human rights violations are or how they are to be reported. We recommend to include under Section 3.
CHECK-LIST:
Page 5 of 8 for DMAS #P241a - Competency 3
COMMENT: Reconsider having two supervisory signatures. The smaller programs and some group homes only have one supervisory level person assessing competencies and providing the training needed to reach proficiency. In some cases, there may not be a second person available to observe and assess proficiency. In Day Programs, this is an additional administrative burden for which we were not previously required and will add administrative costs. If we trust supervisory personnel to assess proficiency in other areas, this should be sufficient in this area of the competencies.
COMMENT: Consider revising the competencies for Medical, Autism and Behavior (Forms DMAS #P201, DMAS #P244a and DMAS #P240a) – to streamline these competencies.
COMMENT: There is a concern about the required training for the Medical, Autism and Behavior competencies. There are not many certified training programs out there and those that are - have a cost to them. Most providers do not have access to the professional lists who must sign off on the in-house developed training indicated. This is another disincentive to providing services to those with higher needs.
OVERALL COMMENT:
There are three sections that should be considered optional and not be required for all DSPs or even all supervisors. In these examples of specific job duties, we contend that these requirements would NOT necessarily apply to all staff but might rather be reserved (and specified in job descriptions) to only staff who are assigned to provide these specialized supports:
3.2 “Locates medications and side effect information for all individuals supported, provides safe and accurate delivery of medication; reports unusual reactions, responses and behavior to the appropriate health professional immediately”
COMMENT: While the last phrase of that competency (reporting unusual reactions) applies to all staff, there are some staff who never deliver medications so the initial phrases about locating medications and side effect information as well as the actual delivery of medications should NOT pertain to all DSPs and supervisors.
3.3 “Correctly follows nutrition plans and meal preparation guidelines including the use of thickeners, special textured food preparation such as pureed and chopped consistencies and uses the correct utensils for all individuals supported”.
COMMENT: We again propose that not all DSPs and supervisors support individuals requiring this level of support. Even with the number of individuals discharged from Training Centers, these specific meal preparation guidelines are limited in applicability and providers should be able to identify (by job descriptions) which DSPs have both this support delivery (and therefore competency) requirement.
3.4 “Operates and maintains adaptive, orthopedic, and communicative equipment correctly” – COMMENT: Same comment as above: These competencies are essential when needed in specific job descriptions but should not be a requirement for all DSPs and supervisors.
ServiceSource Comments on DSP Competencies
ServiceSource appreciated the opportunity to partner with DBHDS to pilot a revised version of the competency checklist. Our staff comments below are based on that pilot experience as well as the posted new versions of the checklist and competency protocol.
The process has been improved
Suggestions for further improvement
Suggestions for change (specific to checklist)
Suggestions for Further Improvement and Recommended Changes:
An electronic version would be more useful for several reasons, including:
· The physical space for comments varies in the new paper draft version. An electronic version would allow expansion of space only when needed plus allow for faster entry,completion and easier use when editing the document,thus resulting in an efficient final document.
· This new draft has unfortunately NOT reduced the voluminous requirement of initialing and dating by the supervisor in each section, along with signatures at the end. We propose that electronic signatures at the end of the checklist document would be sufficient and we could eliminate the requirement for initials and dates in each section.
Page 5 of 8 of DMAS #P241a - Competency 3
COMMENT: Reconsider having two supervisory signatures. In some cases, there may not be a second person available to observe and assess proficiency. This seems duplicative and again increases the administrative time and ability to efficiently complete the required paperwork.
COMMENT: Consider revising the competencies for Medical, Autism and Behavior (Forms DMAS #P201, DMAS #P244a; and DMAS #P240a) - to streamline these competencies.
COMMENT: There is a concern about the required training for the Medical, Autism and Behavior competencies. There are not many certified training programs available and those that are available - have a cost to them. An additional administrative and programmatic cost not captured in the rate. Most providers do not have access to the professional lists who must sign off on the in-house developed training indicated. This is another disincentive to providing services to those with higher needs.
In the DDW DSP Orientation and Competencies Protocol (2019.08.30), on page 9, under “Autism Professionals include” and “Behavioral Professionals include”, behavior analysts should be listed as “a Licensed Behavioral Analyst (LBA), or a Licensed Associate Behavior Analyst (LABA)” as it is not enough in Virginia to be Board Certified, they must also be Licensed. Thank you for your attention.
The competency checklists are not a comprehensive training curriculum. Additionally, why do staff need to be continuously rechecked on competencies they have already demonstrated? Staff do not forget what they have learned each year; they become more competent with years of experience, ongoing training and supervisory feedback.
In review of the updated competency checklist for DBHDS Licensed Providers that has been sent out for public comment, I have the following comments:
I understand that the state is responding to requirements set forth by the DOJ to ensure that the needs of those receiving services are met by qualified staff/professionals. However, using checklists adds an administrative burden to agencies that takes away from the personal support and care that is provided.
It would be more beneficial for the state to utilize online training documentation that can be completed and utilized across agencies to ensure a more thorough and consistent knowledge base when serving those in the state of Virginia. The use of checklist, no matter the updates, continues to be left at the discretion of the person who is completing the form, and does not formally serve as a true identifier of a person’s ability to provide genuine person-centered services. Due to the nature of the work that we do within the service delivery setting having ongoing training and hands on with each direct support professional is something that takes place and does occur; however the use of multiple checklists and requirements for completion get in the way of this process. A more streamlined measure of accurately capturing the knowledge base of the DSPs who currently provide services throughout the state of Virginia needs attention. The development of training material by the department is what is needed. As agencies are left with this requirement, this allows for inconsistency in the information that is being developed and shared. Having a central training curriculum, videos, and testing would allow for DSPs to transition from agency to agency without the need to retake material, etc.
Additionally, the new guidance material indicates that the 8 page document would require additional processing in the amount of two or more times through each DSPs personnel file, as the Competency 3 section is required prior to service delivery in the absence of a proficient staff person, which would indicate that this checklist must first have section 3 completed. Then potentially sections 1 and 2 completed within 180 days with proficiency noted during that time frame as well. This appears to be a focus away from service delivery and more on the completion of a checklist.
The noted requirement for a complete retest of the DD Waiver Orientation Exam for DSPs who do not demonstrate proficiency within the 180 required days is not appropriate, in that having a DSP retake an exam that they have successfully passed appears to be disconnected. The system in which these competencies were designed appear to overlook the reality of true service delivery. As Provider agencies, we want our staff to demonstrate proficiency in the care that they provide; however, the current system in which these are implemented is not the appropriate answer.
Finally, with regards to reevaluation of competency, it is unclear as to why a repeat of proficiency/competence is needed after the DSP is determined to meet the requirements. In reality, if a DSP meets competency on day 140 then why would they not meet that same competency on day 366.
Provider Agencies around the commonwealth are more than willing to maintain compliance based on the regulations and requirements. However, we seek to have meaningful ways to achieve said requirements and do not feel that increasing the amount of administrative requirements increases the care provided to those receiving services within the state of Virginia.
“Training and competencies must be initiated by the provider upon notification of the individual’s assignment to level 5, 6 or 7 or the approval of the customized rate and completed within 180 days if the provider cannot show that comparable training specific to the needs of the individual has not already been completed.” (Medicaid Memo – 9/1/2017)
This creates unreasonable administrative burden due to completing unnecessary and irrelevant training. The specific needs of an individual may prompt an assignment to a higher level seldom wait up to 180 days to be addressed. Also, the training needed for any staff must be addressed when the need is identified not when a SIS is updated!
Initially, I think it is important to note that the competencies program expansion and checklist were not included in the original Burns analysis for establishing the current reimbursement rate and as a result represents an additional significant (time, money and resources) unfunded mandate in its current form and efforts should be made to decrease not increase the burden imposed, until compensation rates are adjusted to permit compliance without further reductions in relative pay levels which can only worsen the staffing crisis that confronts providers in the Commonwealth.
The annual update requirement and the five-year re-review should be eliminated. Proficiency is defined by demonstration of all aspects of the skill or action “on a routine basis in practice”, but an annual update and the documentation of additional observations at the five-year review do not measure this it only measures a person’s ability to adequately demonstrate the skill or action on a couple of specific occasions, typically when they know they’re being observed/evaluated. Thus, the states instrument fails to measure the outcome it attempts to prove; rendering it a useless unfunded paperwork requirement completely unrelated to actual proficiency. After proficiency is initially established, tracking lapses in any skill or action and comparing them to the total number of times that skill/action was attempted/warranted would be the only way to truly measure whether or not it was being demonstrated “on a routine basis in practice”. This type of tracking not only measures the outcome better but is also more conducive to achieving the goals stated on page 1 in real time rather than an annual or five-year timeframe. Currently, competency lapses in any area are tracked and corrective action is taken as a part of our risk management and quality review program. The state could easily make this a criteria in the often promised required thresholds and triggers areas, providing better measurement, quicker corrective action and a significant reduction in the onerous burden of this unfunded mandate.
The requirements for the advanced competencies are internally contradictory, include new provisions that would create a significant unfunded mandate, are in direct conflict with HCBS choice rights and have no basis in fact that warrants their inclusion. 1st – contradictory – Page 9 clearly reads that to serve individuals in higher tiers all 3 the advanced competencies must be completed; however, in the graph on page 11 the box indicates that only the applicable advanced competencies need to be completed – hope page 11 is right – should be, but clarification is required. 2nd – significant unfunded mandate – the requirement for advanced competency training to be accessed through “ nationally recognized or developed or approved by a qualified professional” with a very exclusive list of who qualifies could be a significantly huge unfunded mandate in that it would require a provider to either contract with a national training agency who has a near monopoly on that type of training making it very expensive or have qualified individuals in the house, who given the qualifications would be very expensive as well. This huge unfunded mandate would fall particularly hard on small providers who would have to make a choice between not providing services to individuals in the higher tiers (which would unfairly preclude them from obtaining the higher reimbursement rates that go along with those tiers and thus significantly unfairly disadvantaged the small business); or pay the significant unfunded mandate and reduce the starting and relative wages (they get no increase when the rest of the world does) of their staff, until they can’t find anymore; or they’re just driven under by trying either way until they are eventually out of business. Remember, the Burns analysis made no provision for “profit” and laughed at the idea, indicating with economies of scale you could probably “find some somewhere” – but small businesses do not have the economies of scale and the current mandate is already causing hardship adding this to it could well cause destruction. 3rd – HCBS choice rights infringed – Individuals would find their HCBS rights seriously curtailed, universally because as small providers go out of business individuals are left with only large bureaucratic providers to choose among and specifically individuals who through no fault of their own find themselves in higher tiers would also find their choices significantly reduced, as small providers who could not afford the cost would be excluded from the pool of available choices, forcing them into large bureaucratic organizations. 4th – unwarranted changes – there is no established basis in fact which makes this provision necessary, given the current training requirements for behavioral supports, health and medication management which already meet the qualifications listed, all of the materials necessary to train for these competencies are already provided and individuals can obtain the competencies without additional specific trainings in most cases and current regulations requiring the provider to demonstrate the ability to meet the Individual’s needs are sufficient without these provisions. Recommend clarification that any additional trainings required to meet this standard would only be applicable on an individually assessed need not as a general requirement or exemption/provision for the protections of small businesses from the requirement as required by the administrative process act.
The requirement in competency 3 that all “must be confirmed as competent in all of the skills in competency area 3 prior to working in the absence of staff determined proficient in this area” is unworkable, creates perverse incentives and will be counterproductive for individual served.
1st workability – as written a DSP has to demonstrate competency in “all of the skills” (apparently allowing none to be marked as not applicable N/A), this could take a very long time for a 3rd shift DSP who only works during hours of sleep in a home where people typically sleep through the night making 3.3, 3.4, 3.5, 3.9, 3.8 and 3.10 very difficult to demonstrate when they may have only none are very rare natural opportunities to demonstrate the skill across a year and requiring that there be 2 persons on the 3rd shift until the 2 opportunities appear would be a huge unfunded mandate small businesses simply could not afford. While you may think we could require that the new 3rd shift DSP work day shifts until the skills are demonstrated, this would not be possible for a part-time individual who has a day job (eliminating them from the applicant pool and making a difficult to fill position much more difficult) and it would create an additional unfunded mandate as you had to cover both shifts while trying to assure competencies and skills the DSP will never use. An additional workability concern is the confirmation process, I read the 2 confirmations requirement as 2 separate observations (which could be by the same supervisor); however, other commentators appear to believe it requires 2 separate supervisors to sign off, if they are correct this should be reduced to 1 supervisor to accommodate small businesses where only one may be available.
2nd perverse incentives – this requirement encourages providers to rush the process of determining competency which is directly counter to the 2nd claimed goal “building skills” on page 1 of the protocol as the time to build would not be available, the focus will be on obtaining 2 demonstrations, which would also be counterproductive for goal 1 quality of service in the long run. Many of the observational indicators includes requirements for the DSP to “describe” or “explain” which theoretically could be done 2 days in a row or twice in the same day to confirm competency, a DSP could demonstrate competency in proper data entry by getting it right 2 days in row, even if no significant events to record occur during those days; all of which would meet the competency requirement but not represent the building of skills that we work so diligently to achieve now over already fairly short time frames. Good providers use questions to test these knowledge areas across time (we schedule them across the 1st week, 3rd week and 6th week) in order to ensure information retention and reinforce actual examples where the information was required in their service experience, which provides a much better assurance of competency. However, under this provision diligent providers, who assure a skill competency is achieved before they allow independent performance of the skill, would not be allowed to leave a new DSP providing other services where they have been deemed competent for an individual for an hour or 2 in the afternoon, if the DSP had not fully mastered the tooth brushing or some other non-applicable competency for that timeframe which becomes another unnecessary unfunded mandate that incentivizes reduced diligence in building actual skills/competency. Less diligent providers would be incentivized to just pencil whip through the competencies and use their completion as a rationale to forgo additional skill building efforts, even when needed.
3rd – counterproductive for service quality –a staff stressed provider would be incentivized to encourage frequent repetitions of skill demonstration opportunities that are unnecessary for the individual, just so they can establish the competency and allow the new DSP to proceed to provide independent services. Even a very good provider attempting to establish competency would be required to create situations that are distressing for the individual served – consider 3.11 the observational indicator is “follows evacuation procedures correctly” if this is to be determined by fire or evacuation drills it will significantly increase the number of drills the Individuals served have to suffer through and in our experience this will decrease not only their receptivity to drills but also their ability/motivation to respond in an actual emergency, as when we did them more frequently, individuals served would complain that it was just another drill and some refuse to discontinue their activities or leave, making excessive drills extremely counterproductive for individual safety, but apparently required by this guidance document.
Several other areas of note:
if taken at its word, this process would require all providers to develop a level of proficiency in all DSPs that would make supervision minimally or completely unnecessary, which is not a realistic end state given the applicant pool we can attract due to the low wages required by the current reimbursement rate – if all DSPs are deemed proficient is DBHDS willing to accept the almost total absence of qualified staff supervision in an individual home (which would appear to be inconsistent with other regulations) and if not then why would they require such a high standard be achieved by everyone when it is not necessary given the supervision requirements contained in other areas of the regulations.
Remember each and every individual unfunded mandate uniquely and linearly decreases the compensation we can provide to support staff, a seemingly small cost of $2000 represents a dollar per hour for a single full time DSP or $.20 an hour for 10 full time DSPs for a year and more than double that impact for part-timers; so the funds available for the entry wage and our subsequent raises have already been significantly reduced by the unfunded enhanced competency requirements and would be reduced further by the excessive additional unfunded mandates contained in this guidance document –the current average wage in Virginia is already below the average wage at McDonald’s – how can the state justify calling them professionals, requiring we trained them up to professional standards but only make it possible to pay them unskilled labor rates.
The requirement that supervisors complete the observation and evaluate competencies does not take into account the time required by supervisors to complete for all staff supervised.
How will in-home providers meet the requirement of observation without incurring significant expenses as observation will be done 1:1 as is the nature of in-home services.
Thank-you for the opportunity to provide comments and suggestions for further improvement.
Overall comments: An electronic version of the checklist would be useful for example:
• The physical space for comments varies in the paper draft version. An electronic version would allow expansion of space only when needed, resulting in an efficient final document.
• The draft has not reduced the voluminous requirements of initialing and dating by the supervisor in each section, along with signatures at the end. Electronic signatures at the end of the checklist would be sufficient and eliminate the requirement for initials and dates in each section.
Comment: Definitions: It is recommended that the requirement change to allow for the "competent" level (vs. proficient) to be acceptable for a DSP to begin providing billable services. The definition of "competent" states; "The individual demonstrates all of the skills of actions in column two, but not on a routine basis as appropriate to the skill or action; low level of supervision needed. Competency refers to the bare minimum required for acceptability". This should be rephrased to say, "Competency refers to the minimum requirements for acceptability".
Thank-you for the opportunity to provide comments.
DSP Competencies Checklist:
Comment: Page 5 of 8 for DMAS #P241a - Competency 3. - Reconsider having two supervisory signatures. Smaller programs and some group homes only have one supervisory level assessing competencies and providing the training needed to reach proficiency. In some cases, there may not be a second person available to observe and assess proficiency. In Day Programs this was not previously required and will add administrative burden. If we trust supervisory personnel to assess proficiency in other areas, this should be sufficient in the area of competencies.
Comment: Consider revising the competencies for Medical, Autism, and Behavior (forms DMAS #P201, DMAS #P244a and DMAS #P240a) - to streamline these competencies.
Comment: There is a concern about the required training for the Medical, Autism and Behavior competencies. There are not many certified training programs available and those that are available are costly. Most providers do not have access to the list of professionals who must sign off on the in-house developed training as indicated.
Please consider a 90-day grace period for Competency 3.2 (Provides medication as prescribed) being deemed competent if the provider has a policy for back-up provisions (ie. On-duty supervisor who is responsible) and the DSP is enrolled in a medication administration course. We would not allow a DSP to administer meds until they are trained, but they could work alone being competent in all other areas of Competency 3.
Please consider a hybrid learning approach for the competencies to provide a consistent basis for learning among all DSPs across all providers. Online modules developed by DBHDS would provide a basic knowledge and ensure compliance with the DOJ. This could be tracked and verified by DBHDS. Skills checkoffs and proficiency determination would continue to be the responsibility of the provider.
It should be noted that the training for staff needs to be addressed when the support need is identified for the individual, which may be several weeks in advance of a SIS update.
Consider moving Competency 3 to be first in order and proficiency being determined as the current Competency 1 & Competency 2 sections are verified and established as proficient over the 180 days.