We have concerns related to the proposed changes to the provider manual. We believe that the Draft Manual does not reflect third party accreditation standards or general best practice for providers and that these changes will not benefit client care and will negatively affect the services that we provide in the community. We appreciate the opportunity to provide comments and feedback to DMAS below regarding the following topics:

• Weekly Supervision Requirement
• Retention of Supervision Documentation

Weekly Supervision Requirement

QMHP Requirements (RTS). The Draft Manual requires for a Qualified mental health professional-eligible (“QMHP-E”) that “The QMHP-E staff must have at least one hour of supervision per week by a LMHP, LMHPR, LMHP-S or LMHP-RP which must be documented in the employee file. Evidence of compliance with the QMHP-E criteria must be in the staff file.”[2] In addition, the Draft Manual requires that psychiatric residential treatment facilities (“PRTFs”) must be “accredited by the Joint Commission on Accreditation of Healthcare organizations, the Commission on Accreditation of Rehabilitation Facilities, the Council on Accreditation of Services for Families and Children or by any other accrediting organization with comparable standards that is recognized by the state.” [3]

We believe these standards are in conflict as both The Commission on Accreditation of Rehabilitation Facilities (CARF) and The Joint Commission on Accreditation of Healthcare Organizations (“JCAHO” or “The Joint Commission”) utilize monthly rather than weekly supervisory standards.

Likewise, the CARF supervision standards under Section 2. “General Standards,” actually state that provider organizations are responsible for implementing a clinical supervision policy for all individuals providing direct services (2.A.25). As described below, Pyramid Healthcare’s existing policy dictates that we will conduct individual supervision of clinical staff on at least a monthly basis (or more as needed/required from a licensing perspective). While the CARF manual goes on to state what this supervision should entail regarding ongoing supervision of clinical or direct service personnel, it does not dictate what the frequency should be since that is determined by the provider organization (see below).

In addition, The Joint Commission’s Supervision Requirement HRM.01.04.01, ensuring “Staff are supervised effectively” states at item 1 that “[t]he scope and depth of supervision that staff receive is based on their job duties and responsibilities; their experience with the care, treatment, or services they are providing; and the population(s) served.”[4]

Furthermore, the Draft Manual change with regard to weekly supervision conflicts with the monthly staff supervision standard within our policies and procedure manual that were approved by the Commonwealth of Virginia for our Newport News facility. In addition, Pyramid Healthcare’s policy on supervision in other states dictates that at minimum, supervision will take place monthly. We believe that a monthly rather than weekly supervision requirement reflects clinical best practices across state regulatory agencies as well as robust third party accreditation requirements.

Finally, in addition to recommending alignment with third party accreditation standards, a weekly supervisory requirement is administratively burdensome for providers and logistically challenging to maintain full compliance. If DMAS retains the described Draft Manual language, providers would be required to update policies and procedures with regard to supervision frequency and ensure proper documentation in maintained within the employee’s personnel file. Weekly supervision requirements would be overly burdensome for both supervisors and supervisees and would be likely to result in repeat citations across the provider spectrum. As DMAS is aware with regard to chronic and perpetual workforce challenges within behavioral healthcare and the nature of the services being provided, the day to day reality of unplanned staff absences, paid time off (PTO), supervisor staff turnover, and client-related crises make a weekly supervision requirement unrealistic for high-quality and otherwise compliant providers to remain in line with.

As a result, we recommend the Draft Manual language be amended to state “The scope and depth of supervision that staff receive is based on their job duties and responsibilities; their experience with the care, treatment, or services they are providing; the population(s) served and shall be provided at least monthly,” to better reflect accreditation standards and current internal policies in Virginia and across multiple states.

Retention of Supervision Documentation

QMHP Requirements (RTS) (continued). The Draft Manual requires that items such as supervision “must be documented in the employee file. Evidence of compliance with the QMHP-E criteria must be in the staff file.”[5] DMAS proposes that supervision documentation must be documented in the employee's personnel file. We recommend the language be amended to state that, “supervision documentation be retained and available for review at any time.” In our experience, most states typically are intent on confirming and reviewing supervision documentation and are not as concerned about where the supervision documentation is stored. Pyramid maintains centralized employee and human resources functions utilizing technology platforms and does not retain physical employee files onsite at our facilities, although employee records are available upon request or demand.

Please consider this feedback and make appropriate revisions to the clinical policy in order to ensure a robust network of providers across the full continuum of care for Medicaid substance use treatment and recovery services. Thank you for your support of mental health, behavioral health, and substance use providers in Virginia and for considering my requests on behalf of Pyramid Healthcare. If we can provide any additional information or materials, please contact me at crosier@pyramidhc.com or 667-270-1582. In addition, we invite you or a representative of the Department to reach out and schedule a visit to our Newport News location sometime soon to learn more about our programs and services.

Sincerely,

Collan B. Rosier

Vice President of Government Relations