Virginia Regulatory Town Hall
Department of Medical Assistance Services
Board of Medical Assistance Services

General Notice
Update to Supervisor Assurance Form (DMAS Form P245a)
Date Posted: 5/19/2021
Expiration Date: 10/19/2021
Submitted to Registrar for publication: YES
30 Day Comment Forum closed. Began on 5/19/2021 and ended 6/18/2021   [4 comments]

Supervisor Assurance
[To confirm successful completion of training, testing and competency requirements for the DD Waivers]

I,   __________________________ (print), recognize that, as a condition of
providing services or consultation under the BI, FIS and CL Waivers, the following requirements  must be met. I hereby assure that, as supervisor of these services, the following events have occurred as described.

1) I have reviewed the required training topics (including the characteristics of developmental disabilities and Virginia’s DD Waivers, person-centeredness, positive behavioral supports, effective communication, DBHDS-identified health risks and the appropriate interventions, and best
practices in the support of individuals with developmental disabilities) and
completed the DBHDS online training for supervisors, which details the supervisors’ responsibilities for ensuring DSP training, testing and competency requirements of the BI, FIS and CL waivers.

2) I have obtained a supervisor’s training certificate through the DBHDS Knowledge Center and passed the Orientation Manual test (with a total score of 80% or better).

3) I [or a certified trainer] will ensure that DSPs who will be providing services have received training in the characteristics of developmental  disabilities and Virginia’s DD Waivers, person-centeredness, positive  behavioral supports, effective communication, DBHDS-identified health  risks and the appropriate interventions, and best practices in the support of individuals with developmental disabilities and have passed the Orientation Manual Test (with a total score of 80% or better).

4)  I will complete a DBHDS competency checklist(s) that are maintained in agreement with DBHDS requirements including annual updates and the program director’s (or designee’s) signature to include the DSP and Supervisor’s Competencies Checklist (DMAS P241a) and if working in a 
DBHDS-licensed service the appropriate additional competencies   checklist(s) when supporting individuals at Tier Four based on their completed Supports intensity Scale©.

5) When using the “Orientation Manual for DSPs and Supervisors (July 2016),” I agree NOT to give the manual to DSPs as a self-study tool, but rather to meet with them individually or in small groups to review the content and dialogue about it. I will meet with DSPs who utilize the on-line orientation training for DPSs to facilitate their further understanding of the material and answer questions.

Supervisor’s Signature                                                                     Date

Director/Manager’s Signature (Optional)                                        Date

Agency Name and Address

Please keep this assurance, your training certificate, and competency checklist(s) on file for viewing during a DBHDS Licensing and DMAS Quality Management Review.
(DMAS P245a)

Contact Information
Name / Title: Emily McClellan  / Regulatory Manager
Address: Division of Policy and Research
600 E. Broad St., Suite 1300
Richmond, 23219
Email Address:
Telephone: (804)371-4300    FAX: (804)786-1680    TDD: (800)343-0634