2. Service Definition/critical features

• “The Clubhouse has its own physical space that is observervably separate from mental health center/institutional settings and does not include ‘staff only’ spaces”. While all other areas of the clubhouse building can easily remain open to both members and staff, the removal of staff offices would extremely hinder staff’s ability to complete many of the requirements outlined in this draft. The completion of daily documentation, authorizations, ISPs, CNA’s, etc, requires a designated space in order to be completed in a timely manner and in a manner that is compliant with HIPAA.
• “… including holding clubhouse meetings that are open to members and staff.” While our clubhouse currently holds several daily meetings that are co-run by members and staff, our staff do need to be allowed space and time to discuss the milieu and any concerns that may be protected by HIPAA. Being collectively aware of any changes to a members behavioral, mental, or medical health is essential to providing competent care and it would not be appropriate for other members to be a part of these conversations.

3. Required Service Components

• 2. “Assessments shall be conducted… in person with the member in the member’s home or another location of the member’s/family’s choice”. We are not a home-based program like ACT. We provide services within our program’s building, and the members would be receiving those services within the program’s building. It would not be appropriate or viable to send staff to clients’ homes to complete an assessment for a service that would only be provided at a designated location. Our staff are not trained to complete in-home care and our current staff shortages would not be able to accommodate this.  

4. Provider Qualifications Requirements

• “The maximum staff-to-member ratio shall be one staff to 15 members”.  A ratio of 1 staff to 15 members would not be viable to run our program. I truly believe this would result in the closing of our program, and likely many others. This number does not reflect or consider the number of staff needed to maintain a reasonable workload and keep the program running as the program/building is separate from other services, as it is required to be by these standards.  A program/building must be adequately staffed to ensure coverage for staff who are on lunch break, out sick, on vacation, in the process of being hired or trained, etc. With a membership of around 45, we would be allowed 3 staff members max. This would not be an adequate number to complete daily tasks, even with member participation. It definitively would not be an adequate number of staff to complete the clinical daily tasks, which members cannot complete on behalf of staff (ISP, ASSESSMENTS, SKILL BUILDING, CARE COORDINATION, CRISIS SUPPORT, ETC) or to safely address any mental health crisis concerns as they arise, which they frequently do with the population we serve.
  • In the event that one staff member quits (which is an inevitable part of any program or agency), how will two staff members run a program in the meantime? They would not be able to have vacation days, sick days, or breaks. Furthermore, the basic operations of the program would simply not be manageable, even with equal participation from members.
  • Under these requirements, to be a billable service, each member must receive at least two billable interventions and have detailed documentation on both. At a ratio of 1 to 15, a single staff member would be responsible for providing at least 30 billable interventions within a day and complete documentation on those 30 interventions. In a 5-hour period (which DMAS has set as the daily requirement), that staff member would need to provide 3 billable interventions in each 30-minute period. This is without factoring in staff and member co-meetings, lunch periods in which members are provided a meal, or the unique circumstances that arise within the milieu setting (addressing conflict between members, assisting in task completion, managing mental health concerns as they arise, etc) This would have to be completed on top of any assessments, ISP’s, daily operations such as maintaining the building, etc). It would not be viable for the program to continue operating with a 1 to 15 ratio, even with equal member participation.

I believe every program should be able to decide how many staff is needed for their program, as the needs for each will inevitably be unique and only the organization is able to accurately determine what those needs are. If DMAS insists that a limit be set, I would suggest a foundational limit with additional incremental limits as needed. An example, for a client membership of 50 and below, 5 staff are allowed. For every additional 10 members after 50, 1 additional staff can be hired. That way if we are a smaller program or experience a smaller membership, we still have enough staff to keep the program open.

4.3 Provider Accreditation

• “Clubhouses must acquire and maintain clubhouse international accreditation”. Several of the DMAS requirements under this draft are in direct opposition to the standards outlined by Clubhouse International (CI). Fidelity to BOTH would pose an impossibility.

6. Exclusions and Service Limitations

• 9. Employment supports listed are not reimbursed

Again, these are requirements of the CI standards, and the CI standards highlight the “work-ordered day” and focus on employment as a main service offered by PSR. This would mean that the majority of our day-to-day operations would not be billable. How can a staff member offer 3 separate billable services, per 30-minute period, while also offering job-related skills training and job development to members AND provide community participation/presence with community employers?

• 10. Members receiving Clubhouse may not be authorized to receive the following services: Assertive Community Treatment.

We have several members that attend our program and receive ACT services. We often work collaboratively to help a mutual client receive care. It would be a disservice to require these high-need individuals to choose between two programs that benefit them differently.

8. Additional Documentation Requirements and Utilization Review

• 1 & 2: See concerns under 4 listed above. Unmanageable workload in consideration of the listed client to worker ratio, billable services requirement, and services required outlined by CI that are not reimbursable.
• 4: “An LMHP must review documentation of non-license staff at least every 30 calendar days…”. None of our direct staff are LMHP. Would this require our offsite program director to review at least one progress note per member or per staff each? If this is per member, that would require our program director to review over 40 progress notes every 30 days, which is excessive.

While the concerns noted are extensive, we as a program are excited for further investment in our PSR program and our continued growth toward expanding the quality of services we provide. I sincerely hope DMAS will carefully consider and respond accordingly to the concerns of the staff that have current and ongoing experience serving these communities and providing PSR. The current draft regulations combined with Clubhouse International Standards are unclear, incohesive, and in some areas not viable. We look forward to continuing to grow as a program to meet the growing needs of our community and we hope DMAS takes this unique opportunity to collaborate with PSR workers to enhance the services provided rather than hinder our ability to serve our communities.