I would like to have a cap on caseloads for counselors of 40 pateints per counselor.

I would like to have a cap on the number of patients under one superviosr of 200 patients.

I woudl like for CADC to be cosndered a credible license for counselors to provide care to Medicaid patients.

40 patients per Counselor is an ideal case size, anything greater than 40 the quality of counseling diminishes, especially when dealing with addictions.

There seems to be a shortage of so many providers.  This situation may well become worse as more people gain access to healthcare insurance.  This statement is to strongly endorse any efforts that may already be underway, namely:

Develope a greater array of levels of certifications, especially at lower levels, to facilitate easier access to the fields. Require appropriate supervision and perhaps continuing training, whether onsite or online or separately.

In general, at middle levels, provide more autonomy and responsibility.

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In order to ensure that patients receive the quality of care that is needed there should be a maximum of 40 patients allowed per counselor caseload. These counselors should be allowed to possess a CSAC, CAADC or CADC.  Supervisors should have a cap of 200 patients whom they supervise and a personal caseload maximum of 5 patients.  

There is no set defintion of "Progress towards Compliance" in regards to conditional and provisional licenses. (12VAC35-105-50) If discretion is being left up to the commissioner that is fine, but clarification of "progress" may be useful for future parties. Just something to consider.

The definition of developmental disabilities as listed in Licensure regulations is INCORRECT in that it indicates that conditions must be manifested prior to age 18 but it should be corrected to be prior to age 22.  

As an additional suggestion, the definition MUST BE CONSISTENTLY WORDED in all official references such as those listed in Medicaid Waiver regulations as well as all posted on the DBHDS web site.

For Therapeutic reasons a Counselor’s caseload should not exceed 40 individuals and a supervisor should not oversee more than 200 total cases. When these numbers are exceeded, patients are less likely to receive quality care. Additionally, greater numbers result in a higher burnout rate among clinical staff. It is currently hard enough to find employees who want to work in the MAT field. We should be doing everything in our power to keep the ones we have.

We should also be looking more closely at Co-Occurring treatment facilities. So often we have patients who come in with a range of conditions and we are told to refer these patients out. Looking into a Co-Occurring treatment facility license for a wide range of conditions would be extremely beneficial to the population we serve.

Felons are also, for all intents and purposes prohibited from practicing the field. This is hindering people who could truly help the MAT population. Many times we have patients who when they were younger made a huge mistake; who hasn’t? To punish someone their whole life for something that may have happened once is harsh and unfair.  These limitations, including the barrier crimes list and means for felons to seek exception to gain employment in a DBHDS-regulated facility, should be looked at and revised. We teach patients everyday that just because you detour off the road does not mean you can’t get right back on track and make it to your destination; with this mandate we are not practicing what we preach. How are our patients supposed to believe that we are not judging if we are not allowing them to be our equals.

Medicaid will open so many doors for MAT patients which is why I think anyone with a CADC and a bachelor’s degree or higher should be able to easily endorse into the CSAC. This will allow providers to increase accessibility to Medicaid consumers and increase the workforce able to provide services according to Medicaid standards.

Currently in the state of Virginia nurses cannot pour take homes due to Board of Pharmacy regulating OTP’s. Virginia is one of the only states (if not the only?) that requires a pharmacist and pharmacy technician(s) to provide takehome medication to patients, adding an extra step and extra risk in the takehome process. By allowing nurses to pour take home bottles, as is allowed in most other states, we are eliminating an extra step which eliminates extra risk.

 Currently MAT Facilities are not allowed to be built within a half mile of a daycare or school, drawing an uncomfortable parallel with rules for sex offenders. No other modality of medical treatment requires that the treatment center be some distance from schools and daycare centers, and this further ostracizes and stigmatizes individuals with opiate addiction. MAT patients are people like you and me. They have a stigma society has branded on them and often times I find my patients scared to tell loved ones they are in treatment because of this stigma. This hinders their treatment and recovery process as a whole. We should be working toward eliminating the stigma society has created not highlighting it by codifying it into the law! The fact that this law was created in general is shameful and should never have happened.

Over the years, it has been debated whether a criminal justice degree was a human services degree. The following link, from the state of Virginia, deems criminal justice a human services field: https://www.humanservicesedu.org/virginia-human-services.html

 Could this be added into the definition of a human service degree in QMRP. I have this degree and have worked in this field for numerous years. It is very frustrating to be told you are not a QMRP when, to receive this degree, you must take extensive credits in human services classes. 

we  ensure that patients receive the quality of care that is needed there should be a maximum of 40 patients allowed per counselor caseload. These counselors should be allowed to possess a CSAC, CAADC or CADC.  Supervisors should have a cap of 200 patients whom they supervise and a personal caseload maximum patients.  

Now that the Commonwealth has moved behavioral services to a licensed status, it must be noted that these regulations are not compliant with the Department of Health Professions (DHP) regulations. These DBHDS regulations were last updated prior to the Board of Medicine’s licensure of Behavior Analysts (LBA) and Assistant Behavior Analysts (LABA). Applied Behavior Analysis (ABA) services can provide a highly effective and efficient service to support recovery and independence, and DBHDS should include LBAs and LABAs in these practice areas, as well as within the human right regulations.

In order to protect consumer rights, the implementation of behavioral assessments as well as the design and monitoring of behavior interventions must be completed by licensed professionals (including LBAs and LABAs) operating within their scope of practice in accordance with DHP regulations. Implementation of such interventions requiring a higher level of training, experience and knowledge of behavioral sciences can only be done under delegation with specific schedules of oversight. The definitions in these regulations should be updated to clarify the process by which behavioral assessments and interventions can be developed and implemented, and by whom.

Throughout the document all uses of the term mental retardation should be changed to Developmental Disability. This has been the generally accepted standard nationwide for many years.

Time out is a punishment procedure, and its use should be severely limited. DBHDS should specify that its use is allowed only after assessment and development of an intervention plan by a licensed professional operating within his/her scope of practice and training. DBHDS should further specify that any person subjected to time out must be evaluated by a licensed professional with specific trauma-informed care training as this type of procedure can easily result in trauma for the person placed in time out. DBHDS should consider moving regulations regarding time out to the seclusion and restraint section with similarly limited use, required reporting of each use, and a required debriefing process after each use which includes participation of the licensed professional who assessed and developed the plan that uses time out.

12VAC35-105-20. Definitions
1. “Behavior intervention” means those principles and methods employed by a provider to help an individual receiving services to achieve a positive outcome and to address challenging behavior in a constructive and safe manner. Behavior intervention principles and methods must be employed in accordance with the individualized services plan and written policies and procedures governing service expectations, treatment goals, safety, and security.
“Behavioral treatment plan,” “functional plan,” or “behavioral support plan” means any set of documented procedures that are an integral part of the individualized services plan and are developed on the basis of a systematic data collection, such as a functional assessment, for the purpose of assisting individuals to achieve the following:
1. Improved behavioral functioning and effectiveness;
2. Alleviation of symptoms of psychopathology; or
3. Reduction of challenging behaviors.

Comment:
Behavioral assessments and behavior interventions need to be developed by licensed professionals operating within their scope of practice in accordance with Department of Health (DHP) professions regulations. Implementation of these interventions can only be done under delegation. These definitions should be changed to clarify the process by which they can be developed and implemented.

2. Comment:
Throughout the document all uses of the term mental retardation should be changed from this derogatory term to Developmental Disability. This has been the generally accepted standard nationwide for many years

3. “Licensed mental health professional (LMHP)” means a physician, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker, licensed substance abuse treatment practitioner, licensed marriage and family therapist, or certified psychiatric clinical nurse specialist.

Comment:
These regulations were last updated long before the Board of Medicine began licensing Behavior Analysts (LBA) and Assistant Behavior Analysts (LABA). Given that Applied Behavior Analysis (ABA) services can provide a highly effective and efficient service to support recovery and independence, DBHDS should include LBA and LABA in this category to allow them to be contained in DBHDS regulations such as human right regulations and allow for their use in conducting behavioral assessments and developing behavior intervention plans

4. “Time out” means the involuntary removal of an individual by a staff person from a source of reinforcement to a different, open location for a specified period of time or until the problem behavior has subsided to discontinue or reduce the frequency of problematic behavior.

Comment:
Time out is a punishment procedure and its use should be severely limited. DBHDS should specify that its use is allowed only after assessment and development of an intervention plan by a licenses professional operating within their scope of practice and training. DBHDS should further specify that any person subjected to time out must be evaluated by a licensed professional with specific trauma-informed care competency. This type of procedure can easily result in trauma for the person placed in time out. DBHDS should consider moving this to the seclusion and restraint section with similarly limited use, required reporting of each use and a required debriefing process after each use which includes participation of the licensed professional who assessed and developed the plan that uses time out.

12VAC35-105-800. Policies and Procedures on Behavior Interventions and Supports.

5. Article 6. Behavior Interventions
A. The provider shall implement written policies and procedures that describe the use of behavior interventions, including seclusion, restraint, and time out. The policies and procedures shall:
1. Be consistent with applicable federal and state laws and regulations;
2. Emphasize positive approaches to behavior interventions;
3. List and define behavior interventions in the order of their relative degree of intrusiveness or restrictiveness and the conditions under which they may be used in each
service for each individual;
4. Protect the safety and well-being of the individual at all times, including during fire and other emergencies;
5. Specify the mechanism for monitoring the use of behavior interventions; and
6. Specify the methods for documenting the use of behavior interventions.
B. Employees and contractors trained in behavior support interventions shall implement and monitor all behavior interventions.

Comment:
Now that Commonwealth has moved behavioral services to a licensed status these regs are not compliant with DHP regulations.
DBHDS should change this section regarding behavioral assessment and plan development to specify that they are to be completed by a VA licensed professional operating within his/her scope of practice and training.

6. 12VAC35-105-810. Behavioral Treatment Plan.
A written behavioral treatment plan may be developed as part of the individualized services plan in response to behavioral needs identified through the assessment process. A behavioral treatment plan may include restrictions only if the plan has been developed according to procedures outlined in the human rights regulations. A behavioral treatment plan shall be developed, implemented, and monitored by employees or contractors trained in behavioral treatment.

Comment:
Now that Commonwealth has moved behavioral services to a licensed status these regs are not compliant with DHP regulations.
DBHDS should change this section regarding behavioral assessment and plan development to specify that they are to be completed by a VA licensed professional operating within his/her scope of practice and training.

12VAC35-105-830. Seclusion, Restraint, and Time Out

7. C. Application of time out, seclusion, or restraint shall be documented in the individual’s record and include the following:
Physician’s order for seclusion or mechanical restraint or chemical restraint;

Comment:
Given the potential for misuse and overuse of timeout and the high likelihood of the traumatic effects of timeout when misused, time out should require an order by a licensed clinician. Similar to seclusion and restraint any use of time out should require a formal debriefing procedure which includes an assessment of the individual as well as the effectiveness and appropriateness of the intervention.

Section 20  & 30 Definitions – Every effort must be made to bring the definitions in line with those used by Medicaid and or the Department of Health Professions.  Contradictions and lack of consistency impose a hardship of the providers

Section 60  Modification – In order to accommodate a rapidly changing environment, the process for modification of an existing license needs a complete overhaul to include a streamlined process for adding sites to a current service and for changing the capacity within a specific licensed location.  The current process is burdensome for both the provider and for the Office of Licensing, can limit flexibility needed to provide access to services, and causes financial hardship on the provider.

Section 150  Compliance with applicable laws, regulations and policies – This section is the one that would be the most logical to “interpret” with a guidance document.  As the various relevant federal and state laws and rules are subject to change, apply differently (if at all) to different types of providers, and are monitored by the entity responsible, it would be most appropriate for DBHDS/OL to provide guidance which outlines which aspects of a particular rule the Licensing Specialist may review.  For example, the HCBS “Settings” Rule relevant to locks on bedroom doors in a group home is one easily observed and verified by someone doing an onsite inspection.

Section 210  Fiscal accountability – The requirement for 90 days of operating funds was appropriate when the majority of the services were funded privately or through local contracts.  As the vast majority of the services are now funded through Medicaid and prompt payment rules apply, the 90 reserve is irrelevant for any agency in operation for more than a year.  In recessionary or uncertain times obtaining and/or maintaining a credit line for several million dollars is expensive!

Section 260  Building inspection and classification – Consider combining Sections concerning physical plant

Section 330  Beds – Create a provision that allows the “certification” of a location based on the requirements of size specified in Section 340; this would allow a provider to be more flexible in expanding or reducing licensed capacity without a site inspection.

Section 400  Criminal registry checks – needs to be rewritten to comply with recent additions to the Code of Virginia as others than employees are now subject to background checks

Section 520  Risk management – This section could be strengthened to include some requirements for the provider conducting a root cause analysis of significant incidents, maintaining data of critical events and producing clear written analysis and recommendations to lead to a more robust QI process

Section 540  Access to telephone in emergencies; emergency telephone numbers – This section may need to be brought up to the 21st Century!

Section 645  Initial contacts, screening, admission, assessment, service planning, orientation and discharge – The OL regulations need to be better aligned with the concept of prior authorization for service/payment; in cases where the service must be authorized the admission occurs when that is complete, and prior work is considered a screening.

Section 650  Assessment policy – DBHDS should allow the assessment authorized by the funding source as sufficient.

Section 1180  Sponsor qualification and approval process – The role of the Sponsored Residential Provider needs to be clarified; the current practice does not coincide with these regulations and has become a barrier to placement.  Sections 280, 300, 340, 350, 360 & 380 invest in the provider the authority and responsibility for approving the physical plant, etc.

Now that the Commonwealth has moved behavioral services to a licensed status, it must be noted that these regulations are not compliant with the Department of Health Professions (DHP) regulations. These DBHDS regulations were last updated prior to the Board of Medicine’s licensure of Behavior Analysts (LBA) and Assistant Behavior Analysts (LABA). Applied Behavior Analysis (ABA) services can provide a highly effective and efficient service to support recovery and independence, and DBHDS should include LBAs and LABAs in these practice areas, as well as within the human right regulations.

In order to protect consumer rights, the implementation of behavioral assessments as well as the design and monitoring of behavior interventions must be completed by licensed professionals (including LBAs and LABAs) operating within their scope of practice in accordance with DHP regulations. Implementation of such interventions requiring a higher level of training, experience and knowledge of behavioral sciences can only be done under delegation with specific schedules of oversight. The definitions in these regulations should be updated to clarify the process by which behavioral assessments and interventions can be developed and implemented, and by whom.

Throughout the document all uses of the term mental retardation should be changed to Developmental Disability. This has been the generally accepted standard nationwide for many years.

Time out is a punishment procedure, and its use should be severely limited. DBHDS should specify that its use is allowed only after assessment and development of an intervention plan by a licensed professional operating within his/her scope of practice and training. DBHDS should further specify that any person subjected to time out must be evaluated by a licensed professional with specific trauma-informed care training as this type of procedure can easily result in trauma for the person placed in time out. DBHDS should consider moving regulations regarding time out to the seclusion and restraint section with similarly limited use, required reporting of each use, and a required debriefing process after each use which includes participation of the licensed professional who assessed and developed the plan that uses time out.

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Entered on behalf of both the VB Dept. of Human Services and the Region 5 CSB Quality Leadership committee.  We respectfully request consideration of the following issues during the upcoming review and revision of 12VAC35-105:

1. A general effort to ensure Licensing expectations are consistent with those of other regulatory bodies with oversight responsibilities for providers of Behavioral Health and Developmental Services (e.g. DMAS, DOH, other offices within DBHDS).  Suggestions include:

• Ensure clinical documentation requirements are consistent and streamlined with those of other oversight bodies.

• Clarify that for a provider of multiple services, a single intake assessment is valid for a specified time period (e.g. six months), with updates to confirm the individual meets the eligibility criteria for referral or transfer to another service offered by the provider, vs. requiring the individual to sit through a complete assessment of historical information when the information has been gathered by the provider.

2. Opportunities to streamline processes in terms of issuing licenses.  Suggestions include:

• Reduce the number of licenses for DD/ID day support to two, based on age range.Program descriptions articulate the specifics of programing (e.g. group day, community engagement, and/or community coaching) and populations served (e.g. DD with ID, DD without ID.

• Reduce the number of program types where separate licenses are issued for mental health and substance abuse services in light of the known overlap of these diagnoses among individuals in need of behavioral health services.Program descriptions articulate the specific population served, as well as inclusion and exclusion criteria.

3. Revisions to the language regarding reporting requirements in the area of serious injury reporting.  Suggestions include:

• Clarification of language and expectations with a shift from “Serious Injury” to “Serious Medical Event”.

• Clarify expectations to focus on events that occur during face-to-face service provision or when individuals are under the direct supervision of staff of a licensed provider and which, as a result, involve service provision by employees of agencies licensed by DBHDS.

• Revise language to require reporting of Serious Medical Events within 24 hours or on the next business after weekends and holidays.There would be no detrimental effect to individuals receiving services by this change, nor are DBHDS staff members expected to act on this information during weekends and holidays.

Anthony Sandifer -Essential Family Services

 ***If a notice to reference the “applicable law” is refenced, the associated law(s) should be included within the body of the document or in a guidance document. ***

 Section 30, (is not clearly written or easily understandable)

B. “Providers shall be licensed to provide specific services as defined in this chapter or as determined by the commission.

– The list of services needs updating to reflect support available in the waiver Redesign.

- “…or as determined by the commission” should either be better defined to remove the ambiguity as to the purpose or removed from the regulation.

 Section 40-2A & Section 210A, (does not minimize the economic impact on small business in a manner consistent with stated objectives of applicable law)

- The requirement for 90 days funds or line of credit is unreasonable and unnecessary in a fee-for-service environment

-The ability to obtain a line of credit is dependent on factors that are difficult for small providers to meet or maintain.

 Section 50-3A, (is not clearly written or easily understandable)

Specifically, ‘The length of the license shall be in the sole discretion of the commissioner.”

-Leaving the decision of the length of a license to the sole discretion of the commissioner creates the possibility of inconsistent and biased licensing practices.

-The decision for the length of license should be predicated on clearly defined criteria to ensure all providers receive equal consideration in this decision.

-How is it determined if a provider is granted a 1yr, 2yr or 3yr license?

-What measurable data is used?

 Section 60, (does not minimize the economic impact on small business in a manner consistent with stated objectives of applicable law)

-Does not provide guidance on the timeframe for response from commissioner on a modification application

- Does not establish grievance procedure for denied applications

-If response not received from licensing specialist within defined period, consideration should be given to automatically grant requested modification

B. “Approval of such request shall be at the sole discretion of the commissioner.” This creates an opportunity for inconsistent and bias licensing practices. A transparent and standardized approval criterion should be considered.

 Section 150, (is not clearly written or easily understandable)

-Guidance should be provided to identify the specific areas of each applicable law that is subject to review by licensing.

-The range of applicable law and the application of the law is varied depending on the law, the service provided, the entity, etc.

- Streamlined guidance specific to DBHDS oversight is needed.

 Section 170 – A/E, (does not minimize the economic impact on small business in a manner consistent with stated objectives of applicable law)

- After the investigation is complete, how long does the specialist have to submit their findings in writing to the provider?

-The section does not outline either the requirement of a response form licensing or the period in which the licensing specialist shall respond to the Corrective Action Plan submitted by the provider

- Both the provider and the licensing specialist should be held to a consistent transparent layer of accountability.

-If the specialist does not respond within the defined period, provider must have a defined grievance procedure

-Consideration should be given to invalidate a review that is not conducted within a defined period.

 Section 180-B, (does not minimize the economic impact on small business in a manner consistent with stated objectives of applicable law)

-There is no response time for the specialist to approve or deny the requested change

-The lack of an accountability standard for the licensing specialist has the potential to put a provider at risk of challenges associated with operating a business

-The licensing specialists should have a defined response time

-If response not received in the period provider needs a defined and immediate grievance procedure

-Failure of a specialist to respond within the defined period should give provider the ability to make changes necessary to ensure the continued stability of its business

 Section 180-E (does not minimize the economic impact on small business in a manner consistent with stated objectives of applicable law)

-No reciprocal requirements for notification to provider of individuals intent to end services

(see Section 1240 also)

-Support coordinator responsibility to communicate with Providers?

-Support coordinators state client privacy as reason for not advising the provider that family/individual is seeking alternative support

-Providers notified the day of or the day before services are ended

a. Adds to the challenge to recruit, retain and stabilize staffing

b. Creates opportunities for exploitation (i.e. Support Coordinators paid for connecting individuals with certain providers)

-In addition to defined period to notify providers that their services are ending; also require a documented “mediated” event to determine if the concerns can be worked out between the provider and the individual

 Section 250-A (does not ensure protection of public health, safety and welfare or ensure economic performance of important governmental functions and does not minimize the economic impact on small business in a manner consistent with stated objectives of applicable law)

-Overlooks the unethical practice of direct marketing via staff. (i.e. A DSP working for my company meets a manager from another company. The DSP is told they will be paid .50-$1.00 per hour more if they get the individual to switch providers. This is manipulation and coercion. Not in the best interest of the individual but for the service provider)

-Does not address the unethical practice unsolicited direct marketing to individuals or the families. (i.e. going to homes telling individuals or families they can guarantee increased number of support hours if they switch services. Family/individual are told to tell support coordinator they found a new provider and they want to exercise their freedom of choice. This is manipulation and coercion. Not in the best interest of the individual but for the service provider.

-This section fails to close loops holes for exploitation.

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Section 20

The definition of a serious injury needs to be clarified enabling specialists to apply the regulation consistently and providers to understand and follow the regulation.  Lack of clarity and inconsistent interpretation imposes a hardship on providers when attempting to implement a system to collect data so that reporting requirements can be met involving serious injury. Inconsistent interpretation of the definition of a serious injury by specialists lends to a poorly articulated and non-transferable procedures making it difficult for providers to maintain a system which meets requirements.