The Virginia Sponsored Residential Provider Group (VaSRPG) is a collaboration of 30 agencies throughout Virginia who provide Sponsored Residential Services with an active membership of 75 participants.  VaSRGP is grateful for the opportunity to respond as a group to recent guidance documents for Direct Support Professional and Direct Support Professional Supervisor competencies and appreciates the consideration of our feedback.  For any questions related to this document, you may contact either of the following members: 

Meneika Chandler, Family Sharing, Inc., familysharingmlc@gmail.com, 540-414-4561

John Weatherspoon, Wall Residences, JWeatherspoon@wallresidences.com, 540-250-8928

VaSRPG would like to put forth the following comments on guidance documents related to Proposed Changes for Waiver Regulations for DD services

12VAC30-122-390 - Group home – 6 bed max on group homes. 

COMMENT:  VaSRPG recognizes that residential settings of 6 or fewer beds are the preference for community based services, however, we support comments posted by VNPP which acknowledges ”Providers have experienced years of rate stagnation while trying to accommodate the rising costs – the only remedy  has been to increase the number of operating beds in the home  to gain some economy of scale – the only  alternative is to close the home and remove an option for community living.  Since 1990, the Code of Virginia at §15.2-2291 has supported Group Homes of 8 beds of fewer by classifying them as ‘single family residences.’  To impose a regulatory limit that is more restrictive is both short-sighted and unnecessary.”

12VAC30-122-200 Support Intensity Scale

200.2.a. 4 years between SIS assessments for ages 22 and over.

COMMENT:  VaSRPG feels that this distance of time between assessments is detrimental to assuring proper care of individual.  Currently, requests for re-evaluation are limited and difficult to obtain approval, even when there have been changes to medical or behavioral needs. 

VaSRPG requests that the time frame remain 3 years.  Should the 4 year span remain, VaSRPG request that requesting reassessment due to changes be made easier and allowances be make for appeal of results when the team does not feel the level reflects need.

200.B.2. Notations of exceptional medical/behavioral needs will be investigated and may or may not lead to obtaining the exceptional level of services.

COMMENT:  VaSRPG expresses concern about the lack of transparency in the scoring of SIS assessments and how the levels are determined.  In all other assessments and evaluations, scores are shared with the person being assessed along with determination summary.  Since adopting SIS scoring for rate setting, scoring and interpretation has changed multiple times without transparency. 

VaSRPG requests the following:
- scoring and determination criteria be posted,

- justification of any reduction in level or tier be sent to the individual,

- and an avenue for appeal be provided to the individual who wishes to appeal the determination, as is the right of all service recipients related to their diagnosis and treatment assessing and planning. 

370.7. Environmental Modification

COMMENT:  VaSRPG requests that Environmental Modification Services be allowed for sponsored residential services and group homes in cases in which a person has been living in the home for a lengthy period of time without the need for such modifications and has had a significant change in medical status or mobility/accessibility and it would be a hardship for the individual to be moved to another home that has the needed accommodations available.

390.D.1.e. For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented. 

COMMENT:  VaSRPG requests clarification -how must “review” of documentation be documented

460.C.3. Personal Assistance clarification –  Individuals may receive a combination of personal assistance service, respite service, [ companion, ] and in-home support service as documented in their ISPs but shall not simultaneously receive in-home supports service, personal assistance service, or respite service.

COMMENT:  VaSRPG would like clarification – as it is written, it seems that PA can be provided simultaneously with companion

530.C.1. Residential service limit to 344 days per ISP

COMMENT:  VaSRPG requests a re-evaluation of the number of allowable days of billing per year, as 21 days is an excessive number of non-service days for the great majority of people in Residential services who do not have family members who are able to take them home for visits.  Care providers must continue to provide services during this time as well as pay for additional DSPs and relief staff, though they are unable to receive reimbursement for those non-billable days.  Additionally, assurances that a full year of funds are encapsulated in the 344 days of approved services fails to reflect the additional costs to providers brought on by many of the other regulatory changes such as loss of environmental modifications, risk management and quality improvement requirements, and competency requirements. 

550.B.2.i - Therapeutic Consultation - Telehealth and phone options for visits to be permanent.

COMMENT:  Thank you for this!  Telehealth has allowed us to be able to connect with those we are supporting much more frequently and effectively! Love this change.

550.C.5.a,b,and c - Initial SARs will be approved for only 180 days after which point a new SAR will need to be submitted with accompanying documentation including baseline Data.  Annual renewals will need to have an annual summary of quarterly data.

COMMENT:  Though we understand that the purpose is to assure that plans are meeting the expectation of content, resubmission of a plan for support at 180 will cause delays in continuation of services.  In multiple areas of Virginia, we are unable to receive approval for a Plan for Support on a plan renewal in less than 60 days.  If it is pended, it will be delayed longer.  In addition, initial PFSs will often take 60 to 90 days for authorization.  In these cases, we cannot start services until they are approved which is 3 months into the requested plan time and we will have only 3 months of data or information to submit.  Followed by further delays in Plan renewal authorization at the 180 day end-date.   

We request the removal of the 180 day resubmission requirement and request that the accompanying documentation be required for annual renewal.  

550.E.e.(1)and(2) - quarterlies must include graphs and charts 

COMMENT:  We request that this be modified to read that quarterlies must include summary of progress which may include charts and graphs.

PBSFs rely on team participation for data collection. Surveys within the PBSF community rate data collection as the #1 barrier to plan completion and cite that data is often not completed at all or is completed incorrectly. PBSFs often have to resort to record reviews of alternative documentation that the residential provider uses internally, direct observation during visits/telehealth, and anecdotal reports to measure progress and response to interventions.  Broadening the scope of this requirement to include a summary of progress will allow for presentation of data as it is available and will afford the PBSF opportunity to document on the quarterly the barriers with obtaining proper data so the team can measure progress with team participation.  In addition, it will avoid delay of services to the individual due to pending of authorization by PA when the charts and graphs do not look a particular way.

In addition, VaSRPG would like to advocate that LPCs and LCSWs who are endorsed to provide Positive Behavioral Supports are able to bill at the highest rate along with “Therapist and BCBAs” as follows: 

97139 Therapeutic Consultation, Therapists/Behavior Analysts/Rehab. Engineers

LPCs and LCSWs who provide Therapeutic Consultation for behavior supports are restricted to billing under 97530 as "other professionals" because we are not considered as qualified to provide Therapeutic Behavioral Consultation as a BA. 

Licensed Professional Counselors are Master’s level licensed professionals, completing 4000 supervised clinical hours with 200 direct supervision hours under an LPC.  Likewise, LCSWs are Master’s level licensed professionals, completing 3000 supervised clinical hours with 100 direct supervision hours under an LCSW. In addition to clinical experience, LPC or LCSW with endorsement as a PBSF holds specialized training in evidenced based behavioral support.

Our state struggles to provide quality mental health support to individuals with Developmental Disabilities that also have comorbid conditions related to mental health. In addition to being able to provide interventions for behavioral needs and address behavioral emergencies, PBSFs who are LPCs and LCSWs are uniquely able to integrate resources and strategies related to diagnosed mental health disorders which are contributing to the behavioral needs of the individual as well as evidence based behavioral strategies for behavioral support. 

LPCs and LCSWs holding endorsement as a PBSF offer a specialized level of professional qualification to meet highly complex behavioral and mental health comorbid needs and should be able to bill accordingly.