I want to acknowledge that several common concerns were addressed in this policy revision. Thank you for taking feedback and adjusting! I have some ongoing questions about specific terminology and some requirements that I believe need to be more clearly defined.

1. The parent/guardian requirement is extensive, particularly with “younger clients.” This is something that I think is beneficial when possible. My feedback is to be more specific on certain aspects and to include exceptions to these requirements:

   1. What ages are considered “younger clients?” Without a definition, this becomes very subjective. My experience is primarily with elementary schools, so 3 and 4 years old is “younger” for me while a Kindergartner is pretty average age.

   2. Does the same family member/caregiver have to participate each week? For example, if a child has divorced parents and lives in multiple homes, it would be beneficial to engage a different guardian each week. Or if a client lives with both parents - could hours be combined? So if mom and dad were both participating for 1 hour, would that meet the 2 hour requirement?  It would be very helpful if multiple guardians could be included in the participation. One idea is for the caregivers and guardians to be specified somewhere on the ISP and allow time to be spent with any caregiver or guardian listed on the ISP. This would also be easy to update as needed.

   3. What about situations where children change living arrangements such as foster care? Would a client lose services due to moving to a new foster home in which the guardian was unwilling or unable to participate?

   4. There also needs to be criteria for clients whose guardians are unavailable. For example, what if the primary guardian is hospitalized or has health concerns that renders them unable to participate in services?

   5. My primary concern is that clients are able to access needed services without being penalized for lack of guardian participation. I completely agree that family involvement greatly benefits the client, but many clients may qualify for CPST due to symptoms stemming from lack of guardian involvement in their lives. It often takes time to build trust and rapport with guardians, but that cannot be attempted without initiating services in the first place.

2. Please clarify what is meant by “Administrative Supervision” and the statement that “An LMHP must review documentation of non-licensed team members at least every 30 calendar days as evidenced by a progress note in the individual’s chart written by the LMHP or a co-signature on the non-licensed team member’s progress notes.”. Does this mean that ALL paperwork must be reviewed and signed by an LMHP, or that only some documentation needs to be reviewed? 

   1. For example, I am a QMHP who works as a compliance specialist and have trained many staff on clinical documentation. The current wording sounds like I could not review/approve paperwork even for QMHP-level services. It would be a tremendous help for agencies to be able to utilize QMHPs in this role rather than requiring LMHPs to review all documentation in order to decrease administrative burden on licensed staff.

3. My biggest concern with the current timeline is that I do not believe there will be enough time to complete all of these requirements before the July 1st deadline (DBHDS Licensure, MCO licensing, staff training, etc.). It would be prudent to have a time period of “phasing out” in which the retiring services and the new services overlapped so that clients could more slowly transition into the new services. If licenses will not even be available until the Spring, then several providers will be pushing to get licensure completed, then trying to coordinate with each MCO. Many agencies will likely not be able to start immediately on July 1. I fear that many clients will suddenly be without services or have to be discharged. I know your office may not have complete control over timing, but please advocate for a longer timeline of implementation for the benefit of clients, agencies, and staff.

4. For crisis services, how will agencies to request additional units?

   1. For example, if a client at LON 3 or 4 is experiencing a crisis, they could rapidly use up their permitted hours for a month. If the CANS Lifetime cannot be repeated, how will clients move between LON?

   2. Also, MCOs could deny additional service hours for clients and hold to the current maximum hours allowed despite the additional need. Would agencies need to file a new SRA in that situation? Please elaborate on these processes to ensure that clients are able to receive the services needed and that agencies can properly be reimbursed from MCOs.

   3. It would also be beneficial to allow agencies to refer to their own crisis programs when appropriate. This would increase continuity of services and decrease wait times between services. It is reasonable for agencies to document the clinical necessity for the referral and to ask CPST providers to document/be involved in the decision-making process, but to require referrals to an outside agency poses challenges particularly for rural communities with limited service options.

5. If the CANS Lifetime cannot be repeated, then providers will have to rely on an assessment completed by another agency. How can providers ensure the accuracy of their assessment and conclusions (such as diagnosis or Level of Need)? Is this something an agency can reevaluate if they feel the need?

   1. Additionally, if the CANS Lifetime is relying on client self-reporting, how do we ensure the accuracy of LON? It would be beneficial for this assessment to be released and have a trial period before the initiation of services and for providers to be able to offer feedback before its implementation.

6. Finally, the draft states that referrals to EBPs and collaboration with MCOs are required, but this time is not reimbursable. So an agency is expected to spend much time on Care Coordination without any reimbursement. Please clarify these points or reconsider the requirements as that is a burden on agencies and does not adequately compensate providers or staff for their time. This will also create longer delays to begin services and require clients to be invested enough to engage with a new provider, creating greater chances for service dropouts. 

Thank you for your consideration of the feedback and public comments!