Good evening,

Please see the comments below on behalf of the Virginia Beach Department of Human Services:

3. Required Service Components

3.1 Assessment

2. The assessment shall be conducted by a LMHP, LMHP-R, LMHP-RP, or LMHP-S in person with the member in the member’s home or another location of the member’s/family’s choice. Assessments completed by an LMHP-R, LMHP-RP, or LMHP-S require a LMHP co-signature.

Can the LMHP conduct in-person assessments at the MH Clubhouse? Additional travel time would cut into the number of assessments that can be completed, which may have a negative impact on access to services for individuals over time. This will also place an additional financial burden on providers, increasing mileage reimbursements. Technically, this will also reduce the amount of time spent on assessments, documentation reviews, and direct service provision, as the travel time could be used in-house to complete those tasks.

3.4 Crisis Support

4. Crisis Supports must be provided on an individual basis, with team member(s) providing services with one individual and their natural supports.

            5. In-person support must be offered and available.

Are LMHPs required to be on-call for crisis support in addition to the clinicians in place with Emergency Services? What are the specific qualifications required for this level of on-call support? This will place an additional financial burden on providers, as it will be important to ensure individuals are paid for their on-call time. It may also pose staffing concerns as the providers continue to experience significant shortages.

3.5 Care Coordination

Care coordination services are clinical in nature and typically completed in person with the members.  However, this does not align with the following clubhouse standards:

• • Clubhouse Standards 8 & 14 - No member or staff-only meetings/spaces- confidentiality concerns
  • Clubhouse Standard 10 - Staff’s generalist role- having to put on our clinical hat
  • Clubhouse Standard 15 - Impacts the work-ordered day tasks with clinical services

How are care coordination services currently provided at other clubhouses to ensure confidentiality and the fidelity of the model?

4. Provider Qualification Requirements

4.1 Clubhouse Staff Requirements

1. Licensed Mental Health Professional who holds a current, active, and unrestricted Virginia license from the Department of Health Professions that qualifies them as a LMHP with Clubhouse International training. The LMHP does not need to be a full-time employee and shall be available on call or as needed. The LMHP shall have the ability to provide in-person services and support to members and staff.

• What is the timeframe for the Program Director and LMHPs to receive Clubhouse International training?

2. Program Director who is a LMHP, LMHP-R, LMHP-RP, LMHP-S, or QMHP with Clubhouse International training.

• • When will DMAS have the “provider specialty” available for providers to enroll?
  • Specifically, what type of evidence is needed to show that the provider has initiated the accreditation process? Does Clubhouse International give providers the evidence needed to submit to DMAS?

4.3 Provider Accreditation

To ensure fidelity to the model of the evidence-based practice of Psychosocial Rehabilitation, Clubhouses must acquire and maintain Clubhouse International Accreditation.

All providers shall be accredited within 4 years of the establishment of a new agency by Clubhouse International. Accreditation shall be initiated, and evidence of this initiation submitted to DMAS during enrollment or within 4 years if the agency is new.

• • Will DMAS allow programs to seek CARF accreditation after 1/1/2026, as an alternative to ICCD accreditation, to provide/bill for MH clubhouse services? For example, our agency currently has a CARF accredited program, and it would be less burdensome to add a service under their accreditation than to seek accreditation for the first time with a completely new entity.
  • Will DMAS allow programs that seek CARF accreditation to follow the same deadlines for ICCD accreditation?
  • If a program was accredited by ICCD over 15 years ago, but is not currently, would the program be reconsidered as a “new agency”?
  • Will DMAS consider extending the deadline for programs to implement the MH Clubhouse Services from June 2026 to June 2027? This will allow providers more time to plan and work to hire new staff to assist as there are additional staff requirements. Additionally, it will also give providers time to ensure the individuals served are educated on the changes.

6. Exclusions and Service Limitations  

9. The following employment supports are not reimbursed:

d. Presentations to the business community to seek partnerships in hiring.

• •  If presentations are done with members in the business community seeking partnerships in hiring, why would this NOT be a covered service?
  • Clubhouse Standard #16 indicates that the work done in the clubhouse is exclusively the work generated by the clubhouse in the operation and enhancement of the clubhouse community.
  • Clubhouse Standard #19 indicates that all work in the clubhouse is designed to help members regain self-worth, purpose, and confidence; it is not intended to be job-specific training.

7. Service Authorization

SA Timeframe = 365 Days     Units (per diem) = 240 units

• • With the sunsetting of PSR services on 6/30/26, would members already open to PSR services need a new initial authorization, or will the MCOs honor the existing PSR authorization until it expires?
  • Why are programs only able to bill 240 units (5 days a week)? Shouldn’t it be 313 units annually (6 days a week)? The rate should be commensurate with the additional availability being required. More staff will need to be hired to ensure coverage for the extra day each week, which becomes 52 more days annually.
  • A member has the potential to attend 313 days (Monday-Saturday). This would include any recognized holidays, as per Clubhouse Standard #32 - The clubhouse has recreational and social programs during evenings and on weekends. Holidays are celebrated on the actual day they are observed.

8. Additional Documentation Requirements and Utilization Review

1-3. Progress Notes

• • When does DMAS plan to send out the daily progress note template/structure for clinical documentation?

4. An LMHP must review documentation of non-licensed staff at least every 30 calendar days, as evidenced by a progress note in the member’s chart written by the LMHP or a co-signature on the non-licensed staff’s progress notes. Non-licensed staff include LMHP-Rs, LMHP-RPs, LMHP-Ss, QMHPs, QMHP-Ts, RPRSS, and BHTs.

• • What would the LMHP need to articulate in this “monthly progress note”? Has a template been developed, and will it be clearly outlined in the regulations?
  • What is the rationale for LMHPs co-signing QMHPs’ daily progress notes? This will negatively impact the additional tasks they are being asked to complete since QMHPs complete most of the required documentation for this service. The volume will significantly increase with this task. Is there any consideration for improving the rates to support hiring more licensed staff?

9. Clubhouse Billing Requirements and Information

2. To bill the per diem unit, members must receive a minimum of two required activities on the day of service. At least one of the required activities shall be in-person.

• • Would DMAS clarify and/or give examples of the “two required activities” that a member is to receive on the day of service that are required for reimbursement? It is noted that at least one of the two is required to be in-person.

Additional Questions for Consideration:

Will DMAS provide guidance on ethics and boundaries to programs utilizing the MH Clubhouse Model, as it clearly dictates a collegial relationship between staff and “member”?

• • CSBs/organizations have aligned their ethical policies and procedures with the Virginia Board of Counseling Code of Ethics, Professional Ethical Standards, etc., to ensure client safety. 

What is the hierarchy of governance when there is a conflict with a department policy vs a “clubhouse” standard?

• • Which governing body trumps the other?  Is there any flexibility?
  • What considerations will be given to programs to ensure continued accreditation?