12VAC30-122-80 - Waiver Approval Process; Authorizing & Accessing Services

C. AMEND - 30 calendar days to no later than 90 calendar days for individuals assigned slots to meet with their Support Coordinators  This will allow individuals to avoid Medicaid redetermination. 

12VAC30-122-120 - Provider Requirements

A.12.c. (4) f. (4) - Clarification regarding the term “individual’s unique options”. We assume that this means opinions about their individual supports options”.  However, clarity is needed. 

Comment: We need clarity regarding this definition.  This would be unique to an individual based upon their specific needs, interests, assessments, etc.

A. 19. - MODIFY this semi-annual supervision note requirement for DSP and supervisor of DSPs as “required after the first six months of employment and regularly thereafter.

12. Maintain and retain business records (e.g., licensing or certification records as appropriate) and professional records (e.g., staff training and criminal record check documentation).

e. Providers shall prepare and maintain unique person-centered written documentation in the form of progress notes or supports checklist as defined by the service.   Such documentation shall be written, signed, and dated on the day the described supports were provided. Documentation that occurs after the date services were provided shall be dated with the date the documentation was completed and also include the date the services were provided within the body of the note. Documentation that occurs after the date supports were provided shall be dated for the date the entry is recorded and the date of supports delivery shall be noted in the body of the note.

Comment: We are concerned about the specificity of same day documentation.  There are often legitimate reasons that prevents the staff who rendered the service to document on the same day of service delivery.  In order to maximize hours of service delivery and safety supports within the framework of the provider’s available daily staff hours, there is often insufficient time on the day of service delivery for staff to complete the documentation unless the provider pays overtime on that day for staff to remain at work merely to complete documentation.  One frequent occurrence is that individuals are awaiting a late transportation provider and remain with the provider while staff must directly monitor them until the transportation provider arrives, not allowing time for documentation.  Often the staff must depart immediately after the individual is safely with the transportation provider, due to scheduling needs of the staff outside of this provider, such as a second job or family responsibilities.  Additionally, for providers utilizing direct entry into an electronic health record, there is an automatic date “stamp” but if providers rely on completing documentation in a third party system such as WORD, there could be a delay as the documentation is processed.

We have an additional concern about the inconsistency between the final sentence which suggests how to document if same day documentation did not occur.  While we appreciate this acknowledgement by DMAS that same day documentation may not be possible, we are concerned that the previously stated requirement using the word “shall” about same day documentation might be enforced during an audit regardless of how a provider explains this exception after the fact.

For service providers of Individual Supported Employment, does this mean that providers need to sign and date each time they provide a service? Currently many providers complete one monthly report with one signature ensuring that this report satisfy DMAS requirements that service delivery matches billing for the monthly time period.

12VAC30-122-180 - Orientation Testing; Professional Competency Requirements; Advanced Competency Requirements

1. SUBSTANTIVE CHANGE not Supported or Authorized by Current Statute
   DELETE Individual and Group Supported Employment from list of services.  
   Unless the law is changed, DBHDS/DMAS does not have the authority to require Supported Employment providers to adhere to these requirements if they are DARS vendors of SE services and are CARF accredited. This language is statutory and was originally adopted by the General Assembly, signed by the Governor and chaptered in April 2019.  Also see comments in Section 12VAC300122-400 (Group and Individual SE) to add the following language as a Staff Competency

Comment: An overall recommendation is that, for employment services, there should be consistency with other language within these regulations that specifically defers to DARS requirements to satisfy provider requirements.  Specific to this orientation requirement, we recommend an allowance for agencies who are CARF accredited in community employment to be waived from this Medicaid staff competency requirement.  The Medicaid competency training is NOT focused towards employment services and the time requirements imposed on employment providers to implement and sustain compliance with the requirements is onerous.  As a requirement to become a DARS employment provider, DARS already requires “The availability and use of qualified, competent staff for the provision of services sponsored by DARS and the timelines of those services” and we recommend that this existing DARS requirement also apply to Medicaid employment service providers.  Since the Waiver regulations ALREADY require employment providers to be approved by DARS and to comply with DARS third party accreditation requirements, it would be more efficient to specifically refer to the CARF requirements that employment providers must achieve and sustain:  “Competencies may be assessed in a number of ways, including: Post-tests after trainings; Personnel demonstrating the skill; (and) Certificates of successful course completion.”

B. Proposed competency completion, observation, and checklist within 180 days also applies to contractors.

This is an onerous effort for contractors, who do NOT provide direct services but rather provide specialized therapeutic interventions.  As a large provider, we contract with numerous specialists (such as occupational, physical and speech therapists) to advise direct care staff and to enhance implementation of the service plan, which may involve working directly with the individual.  These contractors typically work independently with numerous agencies and their availability is NOT within the control of an individual provider. These contactors are often on site for very specific time frames (based on our fee for service contracts) and within these limited time frames, there is a time challenge to implement this proposed protocol of reviewing, observing and documenting competencies unless (1) these contractors have additional time availability and (2) the provider is willing and able to compensate the contractors to engage in this competency protocol.

C. Advanced core competency requirements require that staff “shall receive training that is developed or approved by a qualified professional in the areas of health, behavioral needs, autism, or all three, as defined by DMAS”.

Comment: We are concerned that many providers do not have internal personnel resources to include qualified professionals in these areas of health, behavioral needs and/or autism.  Procuring these resources from external sources will result in an additional cost that is not included in the reimbursement rates.  We have an additional concern that this training would need to be “defined by DMAS” since this would require providers to coordinate their procured professionals to have their training curricula approved by DMAS.  Could DMAS offer this training, at no charge, to providers and then require the provider to adjust this “defined” training to the specific individuals who have this SIS assessment level assignment?

12VAC30-122-280 - Benefits Planning Service 

ADD language in this section to reflect the ability to complete this service virtually and/or telephonically - “Benefits Planning Services may be provided in person, over the phone, or virtually via video as is appropriate for each individual serviced.  Written resource materials are to be provided to the individual regardless of the modality of service provision.”

B. DELETE “calendar year” and INSERT “ISP year” to better meet the individualized needs of individuals served and to ensure consistency across services.

B.  ADD - expressly state that “collateral contacts” made during service provision are allowable activities for reimbursement.

C. Service Units & Limitations:

1. INSERT “ISP” between “annual” and “year” for clarification. This should be an ISP year vs. calendar year,

2.  DELETE the “Hourly Limits Per Activity”.  Hours per activity vary drastically from one individual’s situation to another.  RECOMMEND allowing the overall service to be limited to maximum of $3,000 per ISP year without “Hourly Limits Per Activity”.  This would decrease considerable administrative burden by both provider and state pre-authorization specialists. This will allow maximum individualized and person-center services to be provided but still retain the cap of $3,000.

12VAC30-122-400 Group and Individual Supported Employment Service

B. Criteria and allowable activities.

4. Allowable activities for both individual and group supported employment service include the following job development tasks, supports, and training. For DMAS reimbursement to occur, the individual shall be present, unless otherwise noted, when these activities occur:

a. Vocational or job-related discovery or assessment

h. Supports to ensure the individual's health and safety

Comment: We recommend that allowable activities “a” and “h” ALSO be noted that these activities can be conducted WITHOUT the individual being present.  In fact, many discovery and assessment documents are reviewed in the absence of the individual.  Furthermore, the coordination and logistics of arranging health and safety supports, such as coordination with the employment site or family members, would precede the implementation and therefore occur WITHOUT the individual being present.

C. Service units and limits.

Comment: We are concerned that the regulations MUST CLEARLY allow for billing for multiple day and employment services for one individual during the same hour time period.  A valid example would be when an individual is receiving planned supports and skill building in a group day service, based on his or her ISP, while at the same time, other staff representing employment services, are observing/assessing that same individual for the purpose of job discovery.  The job discovery would be a distinct activity related to employment and not logically provided by the group day service staff.  While we understand and accept the requirement for both of these services to be contained within an overall 66 hours within a week, our concern is that billing for two services during the same hour might be problematic.

 7. Individual ineligibility for supported employment service through DARS or IDEA shall be documented in the individual's record, as applicable.

Comment: We recommend that the responsibility for documenting Waiver ineligibility based on DARS or IDEA eligibility should be the responsibility of the Support Coordinator and therefore belongs in Chapter 50 of these regulations rather than Chapter 122.