The current proposed regulations place the existing Crisis Stabilization Units and growing Crisis Receiving Centers (23 hour observation) at risk by eliminating the ability for these critical programs to generate Medicaid revenue upon which they must rely for sustainability.  Of primary concern are the requirements that these programs have 24/7 Registered Nurse (RN) staffing at a time when the America Nursing Association has asked federal agencies to designate the nursing shortage in the US as a national emergency.  There simply are not enough RNs, particularly in rural areas of the state, to meet this need and to recruit these RNs, these services would potentially be pulling resources from our medical hospitals and providers who desperately need them due to the on-going pandemic and national state of emergency. Without the Crisis Stabilization Units in our communities many individuals will not be able to access the necessary care at a time when Virginia’s safety net, the state hospitals are unavailable due in part to the very workforce shortages that these programs will now face related to nursing.  A grace period of 9 to 12 months to meet the nursing requirements in these regulations or allowance to use Licensed Professional Nurses without an RN on site is a more reasonable expectation.

 Nursing assessment should not be required for either the 23 hour observation program nor the Residential Crisis Stabilization Unit.

 The requirement for preadmission screening services to be routed through the regional “Crisis Hotline” is in conflict with the Code of Virginia which requires law enforcement to contact the Community Services Board at the earliest possible time after executing an emergency custody order. This requirement is cumbersome at best and dangerous in creating barriers the Code changes of 2013 sought to overcome.

 The immediate access to psychiatrist or Nurse Practitioner to at the time of admission to both 23 hour observation and Residential Crisis Stabilization will a barrier to care as current availability of on-call psychiatrists and psychiatric Nurse Practitioners does not require assessment 24 hours per day.  Availability by phone should be sufficient.  A requirement for consumers to receive psychiatric evaluation as appropriate in the 23 hour observation service and within 24 hours of admission to Residential Crisis Stabilization Units is more appropriate.  Psychiatric medications will not always be a necessary component of 23 hour observation services and should not be a service requirement.

 These regulations threaten more than 42 acute beds in Region III of Virginia and many areas of Region III are HRSA designated mental health provider shortage areas.  The consequences to our communities will be devastating if enacted as presented.