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.