12VAC35-108-80 (E) - ISP requirement

AHCS agrees staff should be knowledgeable about the contents of the ISP for individuals. The staff knowledge about the contents of the ISP is achieved through observations and during the supervisory and evaluation process. By adding testing of staff after each training would be an unrealistic expectation that may take away from services. Please reconsider this requirement.  

12VAC35-108-160 (A) - "as approved by the department" - Does this mean that policies will need to be approved by OHR or by OL? Please clarify. 

1. 108-50 – Please define waitlist.  Please define how long a person needs to be on a waitlist before a secondary screening is to be completed (for example is a person on a waitlist for 10 days – do they need a new prescreening?)  If a wait list is defined as long than 30 business days prior to being opened for services you may not have to define how long they have to be on the waitlist for a secondary screening. 
2. 108-60.F.1.g --  please define risk factors.
3. 108-60 f.2 c thru e – please remove as these appear to be medical in nature and more aligned with residential or inpatient services and not appropriate for typical home and non-centered based services
4. 108-80 B.7 – Please define a “safety plan”.  Is this required for all individuals regardless of disability type and/or ability to accept their own risk? Please define “identified risk”.  How do we reconcile the requirement of a “safety plan” in an ISP and persons served having control over their own plan and not wanting to include items that they are a risk to themselves or others? Should “if appropriate” be at the beginning of the sentence and not just addressing a fall risk plan?
5. 108-80.E – This feels like a regulation aimed at group homes exclusively and not for every home and non-centered based service.  Should this be specified as to which populations it is aimed at? Please define what is expected as part of a training on someone’s ISP.  Please define how an organization is to test for competency or knowledge… is that a written test? Is that an assessment by the supervisor? Is it a practical demonstration?  Tracking the competency in the “personnel file” will make personnel records unwieldy and difficult to navigate and result in PHI being included in personnel files and will put a huge burden on HR and QI staff to track and file.  Overall, while we do agree that staff members should be generally knowledgeable about individual’s treatment plans, expecting providers to “train and test” staff on service plan is unrealistic and conflicts with providing services.  For example, a program such as ACT may have up to 120 (or more) clients involved at any one time.  Finding a way to train and do a “competency” test for each of the 13+ staff for 120 clients results in in over 1560 competency tests just within that program alone let alone every time a plan is updated or modified throughout the year resulting in a reduction of time available to provide services.  The unintended consequence of this regulation will most likely be less individuals plans and fewer modifications and updates to plans to avoid having to train/retest 13 staff.
6. 108-90.C – please remove as there are not medication only non-centered based services
7. 108-100 – please clarify that this is not stating that every service a provider is licensed for needs to utilize the same note form and is aimed at ensuring that all notes within a service look the same
8. 108-100.B.5 – will there be problems with DBHDS if what was documented in a prior session to be the focus of the upcoming session does not happen due to life circumstances?
9. 108-100.C – please correct to say the provider shall include documentation in the record should the individual no longer need the intensity of care of the specific home an/or centered based service.
10. 108-110.A.5 – please clarify that this is only in regards to any tests, exams assessments, etc. that are ordered by a medical provider employed by the organization and not any outside medical needs that have been ordered by providers
11. 108-120.C.5 – please remove outpatient and inpatient as these are centered based services and therefore do not belong in this chapter.
12. 108-120.C6 – please remove PSR services as these are centered based services and do not belong in this chapter.
13. 108-120.D – please remove as this is specifically regarding residential services
14. 108-160 – What is involved in getting obtaining approval from DBHDS re: emergency plan?  Please indicate who is responsible for approving these plans (Licensing or HR or both) and what the time frames are in regards to getting feedback back from DBHDS about these plans. 
15. 108-220B – how does telehealth impact these “face to face” aspect of the regulations if telehealth is allowed by the DMAS after the PHE?

1. 3. Methods to assist individuals who are not admitted to identify other appropriate services.

Comment: Please remove or clarify. This is the responsibility of Support Coordination not private providers.

2. A. In the event that an individual has been placed on a waitlist prior to receiving services a secondary screening shall be performed prior to admission to the service. The provider shall document:

Comment: According to 12VAC30-122-120, providers cannot have a waitlist as they are expected to be able to serve within 30 calendar days of the referral. Is this regulation contradictory or are we misinterpreting 12VAC30-122-120?

3. 2. After each training, providers shall test the employee’s or contractor’s knowledge, competency or both, and retain documentation of the test of the employee’s or contractor’s knowledge, competency or both within the employee or contractor’s personnel file.

Comment: this places an undue burden on the provider to show competency and is a duplication of effort. This will cause a significant amount of time to create ISP specific tests. We already document our training on ISP’s and ensure understanding of the needs of the person.

4. Describe follow-up care that is needed or note which objective within the ISP will be focused on the next time the individual receives services; and

Comment: please explain the purpose of this regulation.

5. 12VAC35-108-130. Staffing

Comment: Non-center-based day: please reconsider the 1:1 and 1:3 ratios for Coaching and Engagement. Some groups may be larger based on interests and needs.  These services have been very challenging to operate with the low ratios. Allow ratio’s to be defined by needs rather than fixed.

Comments - General Chapter 12VAC35-108

12VAC35-108-10. Definitions.

• Comprehensive assessment – Thank you for recognizing that there are situations where the initial assessment meets the requirements of a comprehensive assessment and that an update is not required. This increases alignment with DMAS expectations for many services.

12VAC35-108-50.A Secondary screening.

Please define waitlist. Also, given the variable nature of the work and programming offered by providers, the census of waitlists should be set by Providers.

12VAC35-108-60.F.2.d Assessment.

Please reconsider the appropriateness as these are non-center based services.  Revise to note provider shall attempt to obtain BAC or administer a breathalyzer, to reflect that individuals have the right of refusal.

12VAC35-108-70 Individualized services plan (ISP)/Individualized support plan/Services planning.

Include language so the ISP section is consistent with Assessment section in that if the initial ISP is comprehensive that there is no need for 2 separate plans – an initial and a comprehensive (if an initial ISP is comprehensive, this should be accepted as sufficient).

12VAC35-108-80.B.1 ISP requirements.

Add language that reflects that each need may not be addressed, but rather those the consumer wants to address are.  Such as each need “per the consumer’s choice which are” documented within the individual’s assessment.

12VAC35-108-80.C ISP requirements.

Revise language so that the copy of the ISP is offered, but the consumer could decline, rather than the plan be “given.”  Experience is that some do not want or decline/refuse a copy.

12VAC35-108-80-E ISP requirements.

While staff members should be knowledgeable about the contents of the ISPs for individuals served, establishing an expectation to train and test all staff members involved with service delivery is an unrealistic expectation that will significantly detract from service delivery.  Observations of competency in and knowledge about providing services is part of the supervisory and evaluation process.  For example, staff of a Large ACT team may serve up to 120 individuals at a time and all staff members may be providing services to these individuals. It is not feasible for all members of the team to be tested on 120 ISPs, each time a plan is revised (with concurrent expectations to increase the frequency of updating ISPs).  This will significantly detract from time available to provide services.  Promoting this is likely to result in providers making fewer updates to ISPs to avoid retraining and testing staff.  It will also promote the development and use of plans that are less individualized. 

There is no realistic way to document this knowledge and competency without documentation of confidential information about individuals served, which should not be part of a Personnel File.  This also places an undue burden on Human Resources staff members who maintain personnel files.  File sizes would become unmanageable. 

Job descriptions already include the minimum requirements and KSAs. Staff are required to be oriented to their position and supervision is to be documented.  Documentation of this would be available to auditors if there was a question of competency.  Perhaps a compromise would be a staff attestation upon the staff signing the Treatment Plan, indicating they have a working knowledge of the plan including health and safety protocols.  If the issue is with specific competencies that DBHDS has concerns about, perhaps those could be enumerated and only those require further education and training.  As written, it is too vague to be accomplished.

12VAC35-108-90.C Reassessments and ISP reviews.

Remove, as this is not applicable for home/non-center based services, which are inherently not medication-only in nature.

12VAC35-108-90.F.3. Reassessments and ISP reviews.

A 15-day grace period conflicts with some DMAS regulations.  Perhaps a grace period should not be referenced in the Licensing regulations, but note the DMAS timelines for that service.  This would eliminate the conflicting information.

12VAC35-108-100.A Progress notes or Other Documentation

Certainly, the format of progress notes across all locations of one service is desirable. However, the format of notes across the various services operated under a single organizational license may need to differ in order to reflect the unique nature of each service and affiliated requirements from pay sources.  Revise this section to reflect that the format of progress notes is to be consistent across all locations of the same service type. Updating the language to better clarify what is meant by “format” would be more beneficial.

12VAC35-108-110.A.5 Health care policy.

Specify that this pertains only to tests, treatments, and examinations provided by or prescribed by the provider.  Assuming this responsibility for other services and types of providers will result in staff members engaging in practices that are beyond their scope.

12VAC35-108-50. Secondary Screening

1. In the event that an individual has been placed on a waitlist prior to receiving services a secondary screening shall be performed prior to the admission to the service.

Comment:  Please provide clarity regarding waitlist.  Does this refer to the individual being informed that they have been placed on a waitlist or is it a period of time between intake and starting services?  If it is a period of time, what would that timeframe be?

12VAC 35-105-80. ISP requirements

A.1        This includes documentation that the individual’s needs require a provider operated home and non-center based setting.

Comment:  Not everyone wants or needs a provider operated home and non-center based setting.  Perhaps and/or could be used.

E.2         After each training, providers shall test the employee’s or contractor’s knowledge, competency, or both, and retain documentation of the test of the employee’s or contractor’s knowledge, competency, or both within the employee or contractor’s personnel file.

Comment:  This is an undue administrative burden for providers requiring that a test be created for each ISP and opening an issue with the possibility of individuals’ PHI being in personnel records.  Staff competency is being observed and documented as required by DMAS and as part of routine supervision.  One commenter suggested that a staff attestation stating that they were trained on the ISP and they understand and are familiar with it as a less onerous option.

E.3         When changes occur to an individual’s ISP, employees or contractors who are responsible for implementing the ISP shall be made aware of the changes, and shall be competent to implement the revised ISP.

Comment:  Please clarify what is expected to demonstrate competency to implement the revised ISP.  Another test is, as stated above in E.2, is an undue administrative burden.

12VAC35-108.130. Staffing.

2. Non-center based day support service shall meet the following staffing requirements:

Comment:  Please make this as flexible as possible!  The DSP workforce crisis may make provision of community-based services extremely difficult, if not impossible, if providers are expected to always have high staff ratios regardless of the individuals and activities involved.