Assessment - Section 3, 3.1 and Section 5. 5.1.1– Assessments should be permitted via telehealth or telemedicine assisted in order to increase access to rural communities, rather than solely face-to-face. Additionally, the CANS-Lifetime is not mentioned as being the required assessment. In order to address level of need for multiple services, CANS-Lifetime should be an approved and billable assessment tool.

ISPs – Section 3, 3.2 – ISP reviews every 90 days are excessive for Clubhouse service model. ISP review should occur annually to align with service authorization period.

Skill Building – Section 3, 3.3.7 – Social skills development activities should not be limited to weekend, evening, and holiday programing.

Crisis – Section 3, 3.4.5 - Specification needed regarding in person support being offered and available. This should be elaborated to state that in person support is offered and available while members are in the Clubhouse or engaged in Clubhouse activities.

LMHP Requirements – Section 4, 4.1.1 – Clubhouse should permit LMHP-Es in lieu of LMHPs if under the supervision of an LMHP. LMHP nor LMHP-E should not be required to receive and attend Clubhouse International training. Training requirements are very expensive and were not adequately assumed in the rate study. If the Program Director receives the required training, then LMHP/Es should not be required to receive Clubhouse-specific training, especially if LMHP is not Fulltime in the clubhouse. LMHPs trained in the assessment, ISP, and supervision should suffice for this service.

Staffing – Section 4, 4.1.3 - Clubhouse should permit the use of BHT-As under the appropriate required supervision to assist with facilitation of RSB, care coordination, and the work-ordered day activities.

Accreditation – Section 4, 4.3 – Providers are able to operate Clubhouse International standards to fidelity without accreditation. CARF Accreditation should be allowable beyond 1/1/26 if this is a permissible substitution for Clubhouse accreditation, but at least accreditation before 7/1/26 for providers who were already in the accreditation process before Clubhouse roll-out.

Diagnostic Criteria – Section 5, 5.1.2a – SMI in the service definitions includes major depressive disorder but it is not listed in this section. Additionally, other diagnoses should be permissible without physician note such as Anxiety, PTSD, personality disorders, etc.. I recommend updating this to include any DSM-V diagnosis to include Autism Spectrum Disorder as individuals with ASD benefit significantly from Clubhouse services.

Continued Stay Criteria – Section 5, 5.2 – Clubhouse International when operated to fidelity is not a time limited service. Progress may be defined as maintenance or stability or lack thereof. There is no such thing as maximum benefit when operating Clubhouse International model to their standards and if accreditation is required, this would need to match DMAS regulations. Risk of deterioration without continued support should be a substantial enough continued stay measure, however continued stay authorizations should be removed entirely and registrations of services put in their place.

Discharge Criteria – Section 5, 5.2.3 – Services are designed to be accessible long-term and “members for life”. Maintaining treatment goal progress is acceptable for continued services per Clubhouse International. so, removal of both # 1 and 2 should be considered to meet standards.

Exclusionary Criteria – Section 6 – The criteria excluding a Developmental Disability without a co-occurring behavioral health condition is acceptable, however, Autism Spectrum Disorder should be the exception and be allowable if they meet the rest of the eligibility criteria. Additionally, as part of the work ordered day, often intervention is observable. #3 does not make sense for this service. #9a, b, and e, skills training for specific jobs as part of supportive and transitional employment efforts should be permissible which may include supervision, teaching routine work duties, and onsite educational support as part of the work-ordered day. These bullets should be removed or expanded to state that these activities outside of Clubhouse services are not billable. Lastly, services that are not center-based should be removed from exclusionary criteria (ARTS, ACT, CSC, CS, FFT, MST, and TGH) as there are no service component overlaps and clinical supports outside of Clubhouse should be accessible for members if warranted.

Service Authorization – Section 7 - Clubhouse International standards recommend program operation 365 days per year. 240 units per year is not enough to support an accredited Clubhouse. A minimum of 312 units a year would be required for individuals who attend program 5 weekdays and one weekend day weekly. To better align with Clubhouse International standards, a service registration should be done in lieu of an authorization for 365 units/year as MCOs should not dictate the number of days an individual is permitted to attend program. Additionally, supplemental billing for evening program when done in addition to the work ordered day should be outlined. If a member attends the work ordered day, then comes back for evening program, additional billing should be allotted and described in this section.

Documentation Requirements – Section 8 - As part of the work-ordered day, there will be days that members are present in program and participating without teaching or learning new skills independently as facilitated by staff. Current PSR regulations regarding progress notes align more with Clubhouse International standards than how these draft regs are written. Notes should include length of time in service and notation of participation in the minimum required activities for daily logs and monthly notes to document which activities/units/skills were addressed each month as well as progress made in program. LMHP signatures should not be required, but LMHP-E signatures are permissible if under the supervision of an LMHP. Program Director signatures on progress notes should be acceptable regardless of credentials (as they are permitted to be a QMHP). LMHP-Es should be able to operate as LMHPs and sign all clinical documentation.

Section 9 - Billing Requirements – Additional billing specifications needed for evening programing when done separately, but in addition to the work-ordered day. Billing should be subject to one required activity (work ordered day) rather than two activities as this is more in line with Clubhouse International standards.