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.