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.