At the October VACSB meeting, it was stated that CSBs would have the option to choose between CARF accreditation OR Clubhouse International given the costly nature of training and accreditation for CI. The email sent following one of the provider calls, at the request of DMAS, which detailed the required training was the impetus for making the decision to provide choice to CSBs.  This provided great relief!  Upon publishing of the draft regulations, the option for CSBs to choose between CARF or CI is no longer made clear but, rather, only CARF is an option if the CSB is already CARF accredited.  CSBs need to have the option to pursue the path that best fits their program philosophy and budget needs. 

Section 2

The Clubhouse has its own physical space that is observably 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.

Individual choice is emphasized in Clubhouse policies and procedures and members are assured that their participation is fully voluntary.

              Many individuals that are adjudicated NGRI have a conditional release plan that includes PSR for structured supports.  These individuals, along with those on an MOT, are not technically voluntary.  Would they no longer be able to attend clubhouse?  Clubhouses provide the appropriate structured daily activity and monitoring to ensure everyone’s safety and compliance with the CRP and individualized goals.   Please continue to allow for these individuals to attend even if not considered to be “fully” voluntary.

Section 3.2 Service planning

3.2.4. The ISP may be developed through a team approach and must be authorized and overseen by either the Clinical Director or Program Director.

              Please remove “Clinical Director or Program Director”.  Allowing a LMHP, LMHP-R, LMHP-RP, LMHP-S to authorize and oversee the ISP is clinically appropriate.  This aligns with who may complete the assessment as well as the Board of Counseling regulations for QMHPs.  Many CSBs, including ours, already have an intermediate supervisory level with these credentials that do not require the clinical or program director to provide this oversight. A clinical or program director would not have the time to monitor every member’s individual treatment plans or know the individualized needs.

3.3 Rehabilitative Skill Building (RSB)

3.3.3. RSB that assists members with learning the skills necessary to seek, obtain, and maintain independent employment.

              Not all of our members want to or are able to maintain independent employment.  Many see clubhouse as their employment thru their daily task completion at the program (clerical, maintenance, business, and kitchen unit tasks). Can attending a clubhouse program be considered employment and be worked into their ISP goals (as we do currently)?

3.3.8. RSB to achieve independent living includes development of skills to find housing opportunities, communicate with landlord, apartment maintenance, and other tenancy sustaining skill development needed to live independently.

              These are community mental health skill building tasks and asking staff working in a PSR/Clubhouse program to do this level of skill building would be difficult to manage.  PSR focuses on day to day needs and collaborates/monitors/refers individuals to other resources/supports when these concerns are noted by members of the program.

3.4 Crisis Support (entire section)

To provide therapeutic and effective crisis intervention strategies, an employee must have specific training to provide crisis planning, crisis avoidance and crisis intervention. Once again this provides another requirement and layer of training which will be timely and costly to the CSB and staff.  Additionally, these regulations are not at all consistent with Clubhouse International model of care and are eerily similar to the CPST Tier I and Tier II models of care which are also introduced within this Redesign. 

4.4 Clubhouse Operation Requirements

2. The Clubhouse shall have an independent board of directors, or if it is affiliated with a sponsoring agency, it has a separate advisory board comprised of individuals uniquely positioned to provide financial, legal, legislative, employment development, consumer and community support and advocacy for the Clubhouse. Clubhouse holds open forums and has procedures which enable members and staff to actively participate in decision making, generally by consensus, regarding governance, policy making, and the future direction and development of the Clubhouse.

In consultation with Clubhouse International, this board must be distinctly different from an existing board of directors over a CSB.  Appointing additional oversight would pose an additional burden to the program/agency.  What if this additional oversight completely differs from current board of directors, how could this be managed. 

5.1 Clubhouse Admission Criteria

a. Completion of an in-person Comprehensive Needs Assessment by a LMHP, LMHP-R, LMHP-S, or LMHP-RP within 30 days prior to admission.

              This needs clarification and could result in delayed billing and services to those referred to our program.

Part 5.1.2 Diagnostic Criteria

Emphasizing this comment from another individual on the forum:

“This part of the draft states, “Members with diagnoses that fall outside of these categories may be eligible depending on the level of associated long-term disability; in these cases, a physician letter (documentation from a physician) justifying this exception should accompany the service authorization request.”  This is an unnecessary request. The state of Virginia authorizes and grants trust and autonomy to LMHP’s to make quality decisions regarding a member’s diagnosis as well as the associated level of disability and functional impairment stemming from their SMI. Additionally, DMAS requirement to have the LMHP trained in Clubhouse International would further exemplify the LMHP’s expertise and knowledge of who is and who is not appropriate for the service. Asking for a doctor who is completely removed from the ideology of the Clubhouse and who may or may not know the member well (if at all) and having them make a recommendation for specific service is unnecessary and will only result in delayed access to services.” 

This is a great comment…It shows how far out of scope these proposed regulations are. 

Added, are additional burden and time to our psychiatrists and NPs who we/CSBs are already known to have shortages for and who are our most expensive providers.  This does NOT fit with clubhouse model either.

5.2 Continued Stay Criteria

4. There is a reasonable likelihood of continued substantial benefit from active continuation of the services, as demonstrated by objective behavioral/functional measurements of improvement.

a. The member must be expected to improve at this current level of service.

              This is not CI model.  CSBs could be at risk of losing CI accreditation based on these very stringent DMAS regulations interspersed not only here, but throughout the regulations.

6. Exclusions and Service Limitations

10. Members receiving Clubhouse may not be authorized to receive the following services:

i. Addiction and Recovery and Treatment Services (ARTS) Levels: ASAM 2.1-3.7

iii. Assertive Community Treatment

PSR programs regularly serve individuals at varying co-occurring levels of care as well those receiving ACT services. Rehab and treatment are not one in the same and should not be treated as such. 

8. Additional Documentation Requirements and Utilization Review

e. The only staff who may complete a progress note is the staff who delivered the service. It is not permitted for a staff to deliver the service and another staff to document and/or sign the progress notes.

Clubhouse works in a group dynamic.  What if a staff member becomes ill, leaves for an emergency, or is terminated? Can another staff member complete a note with these circumstances? If so, how much time is allotted for notes to be submitted to remain in compliance?