The following suggestions are based on how we operate as a CARF Accredited program that uses the tenants of the Clubhouse Model to lend structure to our services which are provided through evidenced -based practices.
2. Service Definition/Critical Features
The Clubhouse has its own physical space that is observably separate from mental health center/institutional settings and does not include “staff only” spaces.
While our program has its dedicated space as defined, there are “staff only” spaces and locked parts of the building for privacy, security, and risk management purposes.
3. Required Service Components
3.2 Service Planning
4. The ISP may be developed through a team approach and must be authorized and overseen by either the Clinical Director or Program Director.
Please remove “Clinical Director or Program Director”. Allowing a LMHP, LMHP-R, LMHP-RP, LMHP-S to authorize and oversee the ISP is clinically appropriate. This aligns with who may complete the assessment as well as the Board of Counseling regulations for QMHPs. Many CSBs, including ours, already have an intermediate supervisory level with these credentials that do not require the clinical or program director to provide this oversight.
3.3 Rehabilitative Skill Building (RSB)
2. RSB shall be provided in-person.
Please consider use of telehealth as an exception and the following statement: “RSB shall be provided in-person unless conditions for use of telehealth are met in Section 9.2 below”.
4. RSB in the context of short-term, transitional employment opportunities through relationships between the Clubhouse and local businesses
5. RSB that provides supported employment, including on-site and off-site support at a community business worksite.
Many CSBs offer specific supported employment services and are funded by DARs, not Medicaid; these services do not permit transitional employment as described in the Clubhouse model. The intent of the standard is to offer employment opportunities which can be accomplished through providing transitional employment opportunities or referral for supported employment services. Please consider the following statement to replace 4. And 5. : “4. RSB in the context of short-term, transitional employment opportunities through relationships between the Clubhouse and local businesses
OR coordination with, or referral to, supported employment services.
7. Social skill development activities assist in communication-skill restoration and community integration. These activities occur during evening, weekend, and holiday programming organized by members and staff outside of the work-ordered day.
It is burdensome for CSBs, which are government agencies, to offer this schedule for clients if not already budgeted for such coverage. Our staff job descriptions do not include evening, weekend, or government holiday program coverage. We are also sensitive to offering any holiday programming due to the diversity of the program clients (ie non-American, a variety of religious practices). Please consider the following statement: “These activities may occur during evening, weekend, and holiday programming organized by members and staff outside of the work-ordered day.”
3.4 Crisis Support
5. In person support must be offered and available.
Crisis support as described is a reasonable expectation as the services are provided in person and they are not expected 24/7. In the event of after-programming crisis, other CS Crisis Resources are already available.
4 Provider Qualification Requirements
4.1 Clubhouse Staff Requirements
1. Licensed Mental Health Professional who holds a current, active and unrestricted, Virginia license from the Department of Health Professions that qualifies them as a LMHP with Clubhouse International training.
Please remove the training requirement as it suggests comprehensive Clubhouse International training would be expected even for those with CARF Accreditation. This draft policy (4.3) already encourages training for CARF Accredited programs which can be met through Clubhouse International (including development, comprehensive, specialized track, and webinars). Those programs seeking Clubhouse International Accreditation would already be required to have this training.
4.3 Provider Accreditation
Programs providing Clubhouse services who were Commission on Accreditation of Rehabilitation Facilities (CARF) accredited for the program “Community Integration” prior to 1/1/2026, are not required to obtain Clubhouse International Accreditation but are encouraged to complete trainings.
Thank you for recognizing CARF Accreditation! Rather than only “grandfathering in” those with a current CARF Accreditation, consider allowing CSBs to OPT IN to seek CARF Accreditation for “Community Integration”, using the same timeline as noted for other Redesign services. This option will allow CSBs to choose the accreditation that best aligns with their operations while still following the tenets of the clubhouse model as listed in this draft policy.
4.4 Clubhouse Operation Requirements
1. Clubhouse providers shall follow all Clubhouse International Accreditation standards.
Please consider the following statement : “Clubhouse providers shall follow all Clubhouse International Accreditation requirements unless they are CARF-Accredited”. This will allow the CARF-Accredited programs to align with the model but follow their CARF accredited standards.
2. The Clubhouse shall have an independent board of directors, or if it is affiliated with a sponsoring agency, it has a separate advisory board comprised of individuals uniquely positioned to provide financial, legal, legislative, employment development, consumer and community support and advocacy for the Clubhouse.
Clarification: Consider allowing either an independent board of directors OR CSB Board of Directors to meet this requirement. We frequently share information with our CSB Board about the program, especially with regard to finances, accreditation surveys, audits, health department inspections, etc. To have another board would be a duplication of this work and potentially compromise or put in conflict the advisory process.
6. Exclusions and Service Limitations
9b. Staff presence in the workplace to assist with supervision or teaching of routine work duties.
This statement contradicts the Transitional Employment activities for the Clubhouse Model. As part of the chosen Clubhouse model, transitional employment services should be billable. Clarifying that Supported Employment is not a reimbursable service, if it is receiving other forms of reimbursement (such as DARS) is acceptable here.
10. Members receiving Clubhouse may not be authorized to receive the following services: a. Individuals receiving Clubhouse may not receive the following services:
iii. Assertive Community Treatment,
iv. Coordinated Specialty Care,
Please consider whether disallowing authorization for ACT and Coordinated Specialty Care benefits the client; from a tiered- payment system this limit is understandable, however many programs concurrently serve these clients as part of supporting overall community stability.
7. Service Authorization (SA)
7.1 Preservice Authorization Request states that in order to have a completed authorization at the start of services, the initial assessment and the ISP must be submitted within one business day of admission; yet these documents currently have a 30 day period to be completed. The current manual (Sect IV p.20) notes “the FFS service authorization contractor and the MCOs have the discretion to request that providers submit the Comprehensive Needs Assessment for review”. “For mental health services requiring service authorization, the medical record content must corroborate information provided to DMAS or its contractor” (Sect IV p. 25) . Please keep this policy consistent with the current language in the manual (or new versions) as we must follow the individual MCOs’ direction for submitting the authorization for PreService and Concurrent Requests.
8. Additional Documentation Requirements and Utilization Review
1. The progress note must clearly document that the services provided are related to the members’ goals, objectives and interventions in the treatment plan, and are medically necessary and clinically appropriate.
Monthly progress notes, when written to include the necessary elements noted here are sufficient to demonstrate medical necessity and clinical appropriateness. Please do not require this documentation to occur more frequently than monthly.
2.e. The only staff who may complete a progress note is the staff who delivered the service. It is not permitted for a staff to deliver the service and another staff to document and/or sign the progress notes.
As most programs provide multiple activities in a milieu/ team approach within the month the progress note covers, this requirement is confusing. Currently, we have each staff write the monthly progress note for their assigned clients with input from the team. Please delete this requirement or clarify further.
4. An LMHP must review documentation of non-licensed staff at least every 30 calendar days as evidenced by a progress note in the member’s chart written by the LMHP or a co-signature on the non-licensed staff’s progress notes. Non-licensed staff include LMHP-Rs, LMHP-RPs, LMHP-Ss, QMHPs, QMHP-Ts ,RPRSS and BHTs.
This will be a burden for those programs who have few LMHPs on staff. Our ISPs are cosigned by an LMHP at least q 90 days with the review, this seems sufficient to review the non-licensed staff documentation.
9. Clubhouse Billing Requirements and Information
1. One unit of service is one day.
This is one of the best parts of this draft policy! Thank you- this will save countless hours of double- checking billing practices.
2. To bill the per diem unit, members must receive a minimum of two required activities on the day of service. At least one of the required activities shall be in-person.
Please consider a Telehealth option when the program is experiencing unusual circumstances. This is supported by the Clubhouse International Model. We have found during inclement weather, pandemic, etc the use of Telehealth services promoted client engagement when the physical space was temporarily unavailable. Please consider the following statement: “ To bill the per diem unit, members must receive a minimum of two required activities on the day of service. At least one of the required activities shall be in-person.
In extenuating and time-limited circumstances (inclement weather, building power outages, risk for health-related outbreak, etc) telehealth services may be provided temporarily but require at least one face- to- face activity in order to bill the per diem unit.”
Thank you for considering these comments/suggestions.