General Comment: The proposed changes are substantial. Many would create considerable additional staff time and costs to implement. Some seem outside the scope of typical Licensing Regulations, particularly under administration and governance sections, as well as some related to financial planning. Definitions would be best to be updated and aligned with existing DMAS services and language. Overall, the new draft requirements are onerous and will move the system backwards towards more bureaucracy and less service delivery, and shift additional costs to administration and away from client service, all of which are already a significant problem in the Virginia system and getting worse with growing Managed Care Organization (MCO) requirements, etc.

Page 1

Definitions: “Admission date” means the date at which an individual’s services begin.

This only work if “assessment” is a service (defined as not a service later). Suggest change to “Admission date is the date the individual had a case fully opened.” There may also be people who receive emergency services that are not “admitted” as a fully opened case. The suggest change noted would work with that definition as well.

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Definition of Behavioral Treatment Plan

-Could not find reference elsewhere in the document. Suggest deleting as could not find reference elsewhere, some parts redundant and confusing in comparison to “Individual Service Plan.”

Page 3

“Comprehensive assessment” means a comprehensive and written assessment that updates and finalizes the initial assessment. The comprehensive assessment shall consider the individual's needs, strengths, goals, preferences, and abilities within the individual's cultural context and shall be completed in a time period appropriate to the nature and scope of the service provided. The comprehensive assessment includes all relevant social, psychological, medical, and level of care information as the basis for the development of the person-centered comprehensive ISP.

Currently comprehensive assessments are done at intake in Same Day Access. There is no updating or finalizing later unless a person is unable to finish due to a crisis, etc. Suggest taking out the words with strike through above.

Page 5

"Emergency services (crisis intervention)” definition

-Suggest naming this Crisis Intervention, as that appears to be what it is defining. Replace emergency services with crisis intervention throughout the definition, with the exception of adding that it includes pre-screening services completed by emergency services staff.

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“Full time employee” or “employee” means an employee employed on average at least 30 hours of service per week, or 130 hours of service per month.

-Suggest changing to “an employee who is regularly scheduled to work and average of 30 hours” in order to account for instances of FMLA, extended emergency leave, paid time off, etc.

Group Home-

-would want to clarify this does not apply to Host Home sponsored residential providers who may have two clients in their home

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Definition “Initial Assessment” means an assessment conducted prior to or at admission to determine whether the individual meets the service's admission criteria; what the individual's immediate service, health, and safety needs are; and whether the provider has the capability and staffing to provide the needed services. An assessment is not a service.

-Highly Recommend removing this definition completely. No need to label “initial” assessment. Assessment is a billable and important service. The required comprehensive assessment is referred to elsewhere and could suffice. Is the intention of this to refer to a screening? Screenings are also potentially legitimate services such as SBIRTs, SASSI, Primary Care screenings, etc.

“Initial individualized service plan” or “Initial ISP” means a written plan developed and implemented within 24 hours of admission to address immediate service, health, and safety needs as identified within the individual’s initial assessment.

-Clarify, 24 hours of admission to what? The service or the agency? It is not always possible to complete or fully implement an ISP within 24 hours of admission. Comprehensive assessments at intake/admission take a considerable amount of time. Suggest removing the 24 hour requirement.

“Inpatient psychiatric service” definition

-This is confusing when considering Crisis Stabilization and Detox Units are licensed as “Residential” units and different than hospital level settings, particularly considering ASAM criteria. As written, is also confusing with the proposed definition of residential setting. Suggest aligning definition with DMAS when possible.

“Intensive community treatment” definition

-specifies 5 full time staff, and one full time psychiatrist. Seems like ICT would require less psychiatrist time. Sizes of teams should also be able to vary based location and needs. Recommend discontinuing identifying a specific number or staff required and instead focus on how/what services are provide. 

“Intensive In-home Service”  definition … The services shall include 24-hour per day emergency response; crisis treatment; individual and family counseling; life, parenting, and communication skills; and case management and coordination with other services.

-Recommend removing “shall” or change to “may” or “these services shall be available” as not all clients will need every service listed at all times. This also allows other teams to help cover the emergency services portions if needed.

“Intensive Outpatient Services” means treatment provided in a concentrated manner for two or more consecutive hours per day to groups of individuals in a nonresidential setting. This service is provided over a period of time for individuals requiring more intensive services than an outpatient service can provide. Substance abuse intensive Intensive outpatient services shall include multiple group therapy sessions during the week, individual and family therapy, individual monitoring, and case management.

                -Please align with ASAM, DMAS if possible

-Remove the word “Shall” and replace with “can” or “may” or “will make available as needed” Case Management is not part of counseling services, rather, a separate service with its own standards. Many, particularly adults, do not have or want family members involved as their choice, some may only need group and not want or need individual sessions.

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“Medically Managed” definition

-Seems broader than ASAM 4.0 definition and could be misconstrued to also mean 3.7 medically monitored. Don’t see it mentioned elsewhere in the document, therefore recommend removing.

"Medication assisted treatment (Opioid treatment service)" means an intervention strategy that combines outpatient treatment with pharmacotherapy that includes the administering or dispensing of synthetic narcotics, such as methadone or buprenorphine (suboxone), approved by the federal Food and Drug Administration for the purpose of replacing the use of and reducing the craving for opioid substances, such as heroin or other narcotic drugs.

-Medication Assisted Treatment is not just for synthetic narcotics, for example use of Vivitorl, Naltrexone, Antabuse also qualify. Suggest removing the strike through part above.