DD Waiver Manual - Chapter 4 - Part 2 of 2
30-Day Public Comment - vaACCSES

Supported Employment Services

Page 119: Criteria/Allowable Activities
Comment: 

• Recommend that bullets be entirely realigned AND be delineated between Individual SE and Group SE.
• The first sentence indicates that there is one element that is limited to ISE only. However, there are seven elements listed and are provided in GSE services. The “this element is limited…” should be at the end of the previous bullet.  It should state - “Individual job development, with or without the individual present that produces an appropriate job match for the individual and the employer to include job analysis or determining job tasks, or both. This element is limited to ISE only and is not permitted for GSE”
• Allowable activities should allow for reimbursement for collateral contacts, including Workplace Assistance if the service is provided. 
• Staff provision of transportation – need criteria for what is considered “unavailable or inaccessible” and how this is to be documented. 

• States - “For DMAS reimbursement to occur, the individual must be present, unless otherwise noted, when these activities occur:  Vocational or job-related discovery or assessment,

Supports to ensure the individual's health and safety during the hours of work”
Comment: We recommend that the above allowable activities 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.

Page 120: Customized Employment
Comment:  There is nothing indicated in the manual regarding who may provide this service. Under DARS funded CE only ACRE Customized Employment certified specialists may provide this service – is this the expectation for DBHDS or can any ISE employment specialist provide it?

Page 120 - Job Search Planning
Comment:  the following “conduct an analysis of benefits which may be accessed through Benefits Planning” is unclear. Benefits planning is a separate service.  What is the “analysis of benefits” that is being referred to? While most employment specialists can identify when an individual would need that service, it is the role of the support coordinator to refer for the service and coordinate services.  

Page 122: Documentation of the Individual’s Ineligibility for SE Services
5^th Bullet:  States “Documentation of the individual’s ineligibility for supported employment service through DARS or IDEA, as applicable. If the individual is ineligible to receive service through IDEA, documentation is required only for lack of DARS funding. Acceptable documentation for the lack of DARS or IDEA funding would include a letter from either DARS or the local school system or a record of a telephone call, including name, date, and person contacted, documented either in the individual's file maintained by the support coordinator, on the ISP, or on the supported employment provider's supporting documentation. Unless the individual's circumstances change, for example, the individual is seeking a new job, the original verification may be forwarded into the current record or repeated on the supporting documentation on an annual basis”
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 should be indicated as a Support Coordinator responsibility instead of a provider responsibility.

Workplace Assistance

Page 124: Criteria/Allowable Activities
Comment:  ADD “This service is designed to support individuals in competitive, integrated positions for whom all options for independence in regards to appropriate job match, reasonable accommodations, and the utilization of natural supports in the workplace have been explored, exhausted and documented. This service is supplementary to individual supported employment in order to maintain stability in the workplace.”

Page 124 - Paragraph 1
Comment:  Includes a typo. Should read “has learned the basic skills…”

Additionally, there should be information under criteria indicating that natural supports and accommodations are not available for the identified support needs.

Skilled Nursing Services

Overall Comment - Page 140 - 2^nd to last bullet - There is a significant change in the Manual which is in conflict with the DD Waiver regulations regarding the period for which an authorization is completed.  The change is more prescriptive than the regulations and changes the 1-year authorization in line with an individual’s ISP year to a 6-month authorization. The Manual should not be more prescriptive than the regulations.  This places additional burden on providers. A change in this policy needs to go through the regulatory process or legislative process for full vetting.

Group Home Residential

Page 150 - Service Limitations

Comment:  Regulation 12VAC30-122-390 says “March 31, 2021” and the Manual says “May 1, 2021”  Consistency is needed between regulations and Manual.

Page 153 - 1^st Paragraph - Last Sentence

Comment:  Manual states “Each quarterly review will represent the quarterly data.  However, the fourth quarter will provide an annual summary in addition to the fourth quarter data.  This is not authorized in regulations.  Inconsistent.

Sponsored Residential
Page 175 - Last Bullet
Comment:  DELETE last sentence “Four written reviews span the entire ISP year.”  Language is not consistent with other residential services.

Consumer Directed Services & Services Facilitation

Page 203
Comment:  After the description of CD services in general, and before the beginning of what is currently on Page 204, we recommend that you add the following regulatory language in the Manual for clarification and consistency - 12VAC30-122-150, A, 2, d, e, and f

Page 204 - Bullet 1 --
Comment: Recommend clarification around whether or not the EOR must live with the individual receiving services.  Providers often get “pended” for this. 

Page 204 - Last paragraph -  After the first sentence, ADD “If the individual chooses not to have service facilitation, the support coordinator must document which family member or caregiver other than the EOR shall perform all of the duties and meet all of the requirements of a CD services facilitator.”  (VAC1230-122-150, A, 2, e)

Page 205 - Paragraph 3 - “When two individuals who live in the same home….”.  Recommend ADD “If the individual has chosen not to have Services Facilitation, then the family member or caregiver acting in that capacity will be responsible this assessment.”

Page 205 - Paragraph 4 - Recommend the first sentence to say “An individual who has chosen consumer direction may choose, at any time, to voluntarily change all or part of their services to the agency-directed model as long as he/she/they continues to qualify for the specific services.”
Comment:  For example, he/she/they may choose to move just Respite or part of the Personal Care hours to agency, while maintaining all, or a portion of their Personal Care under the consumer-directed model of service.”  Recommend the second sentence in that paragraph to read, “The services facilitator, or family member or caregiver acting in that capacity, and the support coordinator are responsible for assisting….”

Page 205 - Last bullet - If the change recommended above for Rec 1is adopted - this bullet can remain as is.

Page 207 - Paragraph 1 - This is the explanation that needs to be moved up or copied in the CD section above SF.  See recommendation #1.

Page 207 - Paragraph 3 - The second to last sentence in this part is not proper grammar. Recommend - “Transitions from the CCC Plus Waiver to a DD waiver will only occur only on the first day of a month.”  Also, the last sentence should read, “The SF, or family member or caregiver acting in that capacity, has a role to play in this process in order to ensure continuity of care.”

Page 207 - Last Section  Bullet 2 - there needs to be a space between the words "should" and "call" in the last sentence.

Page 208 - Bullet 5 - Recommend to read “For consumer-directed services, the services facilitator, or family member or caregiver acting in that capacity, must submit the Fiscal Agent Request Form to the FE/A and initiate the change in discal employer agent, if applicable, and the change from CCC Plus Waiver services to DD Waiver services.”

Page 209 - Last Bullet - Language is different from regulations - needs consistency and not more prescriptive language. The regs (12VAC30-122-500, B, 4) state “The services facilitator, during routine quarterly visits, shall also review and verify….”  The manual states “routine semi-annual visits”.  This language should be changed to match the regs. The manual should also add “or family member or caregiver acting in that capacity” to that sentence as well. 

Page 210 - Bullet 1 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must be available during standard business hours to the individual or EOR by telephone.”

Page 210 - Bullet 2 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, will assist the individual or EOR….”

Page 210 - Bullet 3 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must complete the assessments, ….”

Page 210 - Bullet 4 - Language inconsistent with regulations.  The regs (12VAC30-122-500, B, 8) state “Service facilitation service shall be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but at a minimum quarterly routine visits shall take place.”  The manual has been changed to say, “Services facilitation will be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but, at a minimum, routine semi-annual visits.” The manual should be changed to match the regs.  Also, the language “or family member or caregiver acting in that capacity” needs to be added. 

Page 210 - Last Sentence - Recommend language change to “The SF, or family member or caregiver acting in that capacity, may not be the individual enrolled….”

Page 211 - 1^st Sentence - Recommend language change to “The SF, or family member or caregiver acting in that capacity, must document….”

Page 211 - 2^nd Sentence - Recommend language change to “Should a CD employee not report for work or terminate employment without notice, the SF or family member or caregiver acting in that capacity, upon the individual’s or EOR’s request….”

Page 211 - Service Documentation & Requirements -

• 1^st Sentence - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must maintain….”
• Bullet 1  - Recommend language change to “his” to “his/her/they” in sentence, “….receipt of training on his responsibility for the accuracy….”
• Bullet 2  - Typo - "hat" should be "that"
• Bullet 3 -  What is considered a “contact”?  This needs clarification.  Also, what is considered “medical record

Page 212 - Bullet 2 -  
Comment:  Language in the Manual should match the regulations. The Manual Language is more prescriptive. The manual reads, “In a situation whereby the individual’s needs have changed significantly, the plan for supports must be reviewed by the provider.”  The regs (12VAC30-122-500, E, 3, g) state “Documentation indicating that desired outcomes and support activities of the plan for supports have been reviewed by the consumer-directed services facilitator provider quarterly, annually, and more often as needed.”  Manual pg 212, bullet 2, the sub-bullets à These sub-bullets do not exist in the regs.  Why are we being made to document MORE than what is in the regs???  Isn’t that considered more restrictive than the regs?

Page 212 - Bullet 3 - It is missing the number of calendar days in the language.  Also, there is no time limit in the regs, so any introduction of a time limit on when the review must be submitted to the Support Coordinator is more restrictive than the regs. 

Page 212 - Bullet 3 - Sub-Bullet 1 - There is no sub-bullet in the regulations.  This needs to be a dark bullet and moved to the left to align with the other bullets.