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Virginia Regulatory Town Hall
Department of Medical Assistance Services
Board of Medical Assistance Services
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10/22/21  2:32 pm
Commenter: Loren Johnson

Residential Crisis Stabilization
  1. Pg. 32 (First bullet): “A psychiatric evaluation by a psychiatrist, nurse practitioner or physician assistant must be available at the time of admission into the service.”
    1. Currently CSUs have 24 hours to complete the evaluation. Recommend clarifying the evaluation must be completed within 24 hours or immediately if an emergency arises. It is also not always good for a client who has been diverted by mobile crisis, or, sent from an ED, to have another evaluation immediately. Nursing vitals would be sufficient.
  2. Pg. 32 (Third bullet): “The Crisis Education and Prevention Plan (CEPP) meeting DBHDS requirements is required for this service and must be current. The CEPP process should be collaborative but must be directed and authorized by a LMHP, LMHP-R, LMHP-RP or LMHP-S.”
    1. The CEPP appears to be replacing the Treatment Plan. Currently Treatment Plans can be completed by QMHP’s and CSAC’s (and trainees). Recommend clarifying how involved the LMHP (and R/S/RP) need to be involved. Do they need to interview the client prior to the CEPP formulation and develop the Plan, or do they only need to be able to review/update and sign off on them?
    2. Recommend DBHDS publish their requirements for the CEPP prior to implementation.
  3. Pg. 32 (Sixth bullet, #3): “The following components must be available to individuals in the treatment program… 3. Nursing on-site 24/7.”

Pg. 35 (Staff Requirements, fifth paragraph): “Nursing services shall be provided by a RN or a LPN working directly under an RN who is present on the unit.”

    1. This is a change from previous, as on-site nursing was not required for Crisis Stabilization, only Withdrawal Management. Now, not only will nursing coverage be required 24/7, but a RN must be present at all times. This will present significant challenges for recruitment and staffing. Recommend Staff Requirements to say “Nursing services shall be provided by a RN or a LPN working directly under an RN who is either present on the unit or available by telephone.”
  1. Pg. 33 (#6): “Medical, psychological, psychiatric, laboratory, and toxicology services available by consult or referral;”
    1. For clarity, recommend “psychological” be replaced with “therapy,” as the usual convention referring to “psychological” treatment refers to care delivered by a psychologist.
    2. Recommend clarifying what “laboratory services” indicates. Does this refer to only being able to complete basic functions such as UDS, BAC, blood glucose readings, etc.? Or is there a need for full laboratory testing?
  2. Pg. 33 (First bullet): “On the day of admission, at a minimum, RCSU providers must provide assessment, psychiatric evaluation and a nursing assessment.”
    1. Currently, psychiatric evaluation is required to be completed within 24 hours, so may not be done on the day of admission. Evening admissions will often not be able to complete these three assessments before midnight. Recommend changing the time frame from “On the day of admission…” to “Within 24 hours of admission…”
  3. Pg. 33 (Second bullet): ” To bill the per diem on subsequent days during the admission, providers must provide daily individual, group or family therapy unless the LMHP, LMHP-R, LMHP-RP or LMHP-S documents the reason why therapy is not clinically appropriate…”
    1. Different clients have different needs. Rather than require the LMHP (S/R/RP) to document daily as to why individual, group, or family therapy is not clinically appropriate, recommend including frequency of therapy services in the Treatment Plan/CEPP.
  4. Pg. 36 (Third paragraph): “Health literacy counseling must be provided by a LMHP, LMHP-R, LMHP-RP, LMHP-S, Nurse Practitioner, Physician Assistant, CSAC*, CSAC Supervisee* or a RN or LPN with at least one year of clinical experience involving medication management.”
    1. Recommend including QMHP and QMHP trainee.
    2. Recommend removing the year of required experience for authorized nurses. It is already difficult finding nurses to hire without limiting the available pool of applicants.
  5. Pg. 36 (Admission Criteria, #2a)

“Individuals must meet all of the following criteria: … The individual is currently under a Temporary Detention Order;” and

pg. 37 (Exclusion Criteria, #3a)

“Any one of the following criteria is sufficient for exclusion from this level of care: … The individual does not voluntarily consent to admission with the following exceptions: 1. The individual has agreed at an involuntary commitment hearing to a voluntary placement within an RCSU and are ordered to remain for 72 hours and must provide 48 hours’ notice of intent to leave; or 2. The individual is committed through an involuntary commitment hearing to an involuntary placement within the RCSU”

    1. These two sections appear to contradict each other. A person can be admitted under a TDO. However, if they are not voluntary and have not had their commitment hearing, it is exclusionary. Recommend adding a third option to the Exclusionary Criteria exceptions, “The individual is under a Temporary Detention Order awaiting their hearing.”
  1. Pg. 33 (last bullet): “Services must be provided in-person with the exception of the psychiatric evaluation and care coordination.”
    1. The initial clinical assessment has been allowed to be completed via telehealth during the Public Health Emergency, with discussion of continuing to allow it following the cessation of the PHE. Recommend including this in the services that are allowed to be completed via telehealth. This would allow better use of scare resources, especially as there is difficulty in hiring sufficient numbers of LMHP’s (and residents/supervisees).
  2. Pg. 36 (9th paragraph): “RNs, LPNs, and Nurse Practitioners shall hold an active license issued by the Virginia Board of Nursing.”
    1. Virginia is a member of the interstate nursing compact, which should allow nurses from other states within the compact to work at the RCSU’s. Recommend adding to the end of that sentence “or from a state participating in the Interstate Nursing Compact.”
  3. Pg. 32 (3rd bullet)

“The Crisis Education and Prevention Plan (CEPP) meeting DBHDS requirements is required for this service and must be current. The CEPP process should be collaborative but must be directed and authorized by a LMHP, LMHP-R, LMHP-RP or LMHP-S.” and

Pg. 36 (first paragraph)

Treatment Planning must be provided by an LMHP, LMHP-R, LMHP-RP, LMHP-S; QMHP-A, QMHP-C, QMHP-E, CSAC* or CSAC Supervisee*.”

  1. Does the CEPP replace the Treatment Plan or is it in addition to it? Both are mentioned in these sections, and the staff who are qualified to complete them require different credentials. Recommend to clarify if the CEPP replaces the Treatment Plan or is in addition to it, and confirm the credentials of the staff who completes it.
  1. Pg. 35 (Staff Requirements, first paragraph): “Residential Crisis Stabilization Units must be staffed with a multi-disciplinary team of physicians, nurses, LMHPs, LMHP-Rs, LMHP-RPs, LMHP-Ss, QMHP-As, QMHP-Cs, QMHP-Es, CSACs CSAC-Supervisees, CSAC-As, RNs, LPNs and a registered peer recovery specialist. Residential aide level staff can also provide services and support under the supervision of an LMHP.”
    1. Are all mentioned providers required to be on staff, or select ones as appropriate to that unit? QMHP-Cs would not be appropriate for an adult program such as this. CSAC-A’s would have very limited capabilities. Recommend changing wording to “Residential Crisis Stabilization Units must be staffed with a multi-disciplinary team, to include as appropriate: physicians, nurses…”


CommentID: 116547