I am a support coordinator and one of my clients was grandfathered in from the day support waiver to the BI waiver.  While this waiver was able to meet his needs then, when the transition took place, it took away some of the other supports he was able to access through other sources.  The family used IFSP funds to cover respite services and with the transition to the BI waiver they are not longer able to do so.  Other resources have been explored (DARS) but you can only access them once.  The client now needs behavioral consultation services and is not able to access those services as they are not offered under the BI waiver.  Please consider expanding services under the BI wavier that would allow persons with this wavier whom are not appropriate for independent living to access other services that would meet their current needs.  

I have read through or scanned some of the subjects of this new manual. It is easy to read and understand. I thank you for the time spent putting this together for our use. 

Hello,  The BI Waiver needs to add In-Home services.  How is one supposed to build independence in skills if this service is not applicable.  One can't move out and live independently if they don't have the proper skills.  Virginia has come a long way with types of waivers; however, the waiver categories don't fit everyone's needs and the waiting list is just still too high.  The BI waiver definition needs to be revamped.  

Over the past several years, we have had 5 to 6 different SC's.  Each time we have to get acquainted again with a new SC.  The beginning to the end, we must go over our case again.  I feel like we repeat ourself continuously.  In some cases, we (as the family) has to train the next SC on their roles and responsibilities which can be very frustrating at times.  Clearly the DOJ requirements are running SC's away and honestly I don't blame them.  As a family, we continuously have to answer questions repeatedly for one form or another and some forms each month.  I am not 100% convinced these requirements are benefitting my family member. 

I know we have choices with services, but there is not many options to choose from as many providers have closed down.  The caseloads are way to high and quite frankly it can be hard to get in contact with a SC quickly.  I can't imagine the paperwork they have to complete behind the scenes and yet - it doesn't benefit my family member.  DBHDS seems to have many many staff to critique and go over everything, but DBHDS can't help with the day to day needs.  Transportation is desperately needed and I would love to keep one SC for more than a few months.  This is not a "manual" issue but an overall system issue that needs to be pulled together and reviewed.  Truly, how many "Human Rights" forms does one need to sign?  If we sign a Choice of Provider form, it should stay in effect until we revoke or change providers.  Administratively if something is reduced, we might keep a SC.  Continuous changing of SC's really upsets my family member.  They don't take changes easily as others.    Please please think about these requirements.  If not, it's not even helpful to have a SC because they are truly not paying attention to the individual's needs.

Agencies need to make an reasonable accommodation for the DSPs to give all medications to clients who cannot do it themselves.  Theres needs to be clarification and word changing to the policy on agency-directed and consumer-directed that allow personal attendants to administer medications.  Also, there should be clarification between medication moniotring and administration.  If attendants are not allowed to give medications that puts people with disabilities at risk of being forced to go to a nursing home which violates ADA rights to live in the least restrictive environment possible. 

We really should not be forced to have a CSB for case management.  This takes away our freedom to choose the Case Manager that we would like to have.  People with disabilities are supposed to live in the least restrictive environment possible, and have a life like yours.  Forcing us to have a CSB violates our freedom of choice.

1. There appears to be a conflict of requirements as it relates to discharge from services. The DDWS Manual, section Provider Participation Requirements under Therapeutic Consultation Service, indicates "a final disposition summary is to be forward to support coordinator within 30 days following the end of the service" (pg 147). However, in the same manual, section Quality Management and Utilization Review under Provider Discontinues Services states, "In non-emergency situations in which a participating provider intends to discontinue services to an individual, the provider will give the individual or family/caregiver, and support coordinator/case manager ten (10) days advance written notice for services provided in non-residential settings." (pg 25)

Which requirement does Therapeutic Consultation Services abide by? Please note that after the individual's end date on a service authorization, a provider may not upload documents into WaMS due to a WaMS feature to end the provider's access to the individual after the last date of the authorization.  

2. Source DDWS Manual, section Therapeutic Consultation (pg 59).
   1. We find there is a pressing need for Nursing Consultation Services to assess for possible medical conditions that may attribute to behavioral displays, help with recommendations to medical providers as to why a particular test is being requested based on clinical assessments and observations, evaluate for medication interactions, and navigate the caregivers through the medical language. There is not always a need for the level of care provided by skilled nursing or home health.  The nurse consultant is less expensive than skilled nursing or in-home and can provide a broader range of education. Our individuals are aging and facing barriers with primary health care, such as acquire comorbidity diagnoses, multiple medical providers without continuity of care between disciplines, lack of medical providers who see our population, and lack of staff/caregiver resources to understand quality health care practices.
   2. I am surprised a BCaBA or a LABA (assistant/associate), who have limited skill sets set forth by the BCBA Board, can bill at the same rate as a BCBA or LBA. The final approved regulations in 2017 did not allow for BCaBA or LABA's to provide behavior consultation services. The requirements for a BCaBA are a BS degree with 225 hours of ABA theories and 1300 of supervision. If assistants are allowed to perform Therapeutic Consultation Services, we should approve COTA's, PTA's, SLPA's, and proposed PBSF-A.
   3. I suggest that PBSF's who have a minimum of a BS degree with one year of classroom work and one year of supervision should be paid equal to the BCaBA/LABA at code 97139. LCSW and LPC should be paid at the 97139 rates.

3. Telehealth Services Supplement, section Definitions (pg 1).
   4. Telemedicine does not include an audio-only telephone. There are 697,000 Virginians who do not have access to a wired internet connection. https://broadbandnow.com/Virginia
   5. People in the Commonwealth of Virginian who have limited or no access to internet service are due to rural geographic location, lack of connectivity, lack of money to pay for internet, or lack of skill set to use the internet. Lack of access to a video meeting should not negate the fact of the desired access to care. This limitation of no audio is a direct violation of an individual's human rights by denying them access to care.
   6. Waiver consultation codes of 97139 and 97530 are missing from the Code Table (Attachment A)

The new regulations for Private Duty Nursing is impossible to adhere to due to the lack of Nurses world wide.  The individuals we care for have very high medical needs and we provide a nurse for direct care 24 hours a day in the homes.  Under the new guidelines, I would no longer only need 2 nurses a day but now 8 nurses a day (an impossible task in todays job market).  Also, at the current reimbursement rate for Private Duty Nursing which is $26,36.  In our region, LPN's now make between $25 to $28 and hour.  Under the new regulations I would be making $35.52 a day just on nurses salaries alone. This does not include taxes, benefits and equipment needed for their jobs.  If this goes through we will have to close our business and put close to 50 people out of work.  This is all bad news but this is not the worst of it.  Our individuals would be forced to return to living in much more restrictive environment such as a long term care facility or a nursing home. They will no longer go to the park, the zoo, the beach....they will stare at the 4 walls of their facility room.  Also, they will get sub par care.  The nursing ratio in these facilities are much worse, sometime 1 nurse to 30 patients.  So for our individuals they will be forgotten as they don't speak and they cant pick up the nurses button to call for attention.  This is a disgrace and must be changed immediately.

The reduction in the allowed amount of skilled nursing services, from 42 hours a week to 21, creates a hardship for individuals in the community with complex medical conditions.  Many individuals formerly had round the clock nursing care in state institutions.  Their needs generally do not improve over time, but become more complex as individuals age, chronic conditions worsen or become more difficult to manage, new conditions develop (medication allergies, seizures, strokes, heart attacks, COVID, etc.)  Community nursing supports need to increase, or at least be maintained at the current level - not decrease.  We do our best to help individuals receive the care they need in integrated community settings, but we need systematic supports to maintain this.

To the authors of this manual, thank you so much for creating this much-needed guidance.  I think that it will really help providers further navigate the process of caring for someone who receives DD waiver assistance. 

I noticed a significant change in the provider manual (that's not in the new DD waivers regulations) in the area of authorization period length for Skilled and Private Duty nursing.  Currently, the authorization period is a maximum of one year, in line with an individual's ISP year dates, but the manual shortens that max to every 6 months.  The waiver nursing service authorization request process is not quick or easy.  A provider has to keep track of the varying timelines and deadlines which may be different for each individual they serve, obtain multiple signatures from PCPs who are often hard to pin down in a timely manner, keep up with the ever-changing requirements from DBHDS service authorization, navigate their local CSB's staffing situations so that they can ensure that someone knows there's a service authorization request ready to be passed on, I could go on and on.  Please keep the requirement at once a year instead of twice.  I get that the intent, the spirit of the every "six months" requirement is to ensure that more health issues are seen and treated before they have a chance to turn into big problems and I agree with that intention; however, I don't think that this is a good way to do that.  The returns will not justify the costs in this scenario; there will be double the administrative work (time and money taken away from direct care of the individual) for questionable amounts of improvement in health outcomes that you won't even be able to statistically link to this change because of the many other coexisting variables.  Double the administrative work in the hopes of improved health outcomes that can only be linked to that increase as correlation, not causation, isn't a good use of resources.  Please reconsider that change.  Thank you for your time.

Developmental Disabilities Waivers – Chapter 2 page 4 – fingerprint verifications – the 1st subitem in this section indicates that providers "must retain" "documentation" to verify that fingerprints were "obtained and sent" to the company (presumably DBHDS in this case). Recent changes in the DBHDS system to require that the FIELDPRINT system be used for fingerprint checks has reduced the ability of the provider to document the required information for this verification process. Specifically, the provider no longer takes the fingerprints nor has any control over their actually being sent which means the provider generates no independent information or actions that can be used to meet these verification requirements; rather they would be completely dependent on what FIELDPRINT reports on their website post a new employee's appointment. Unfortunately, FIELDPRINT does not always provide accurate information on their website and have demonstrated little to no interest in correcting inaccurate information when it appears. We have only had to use the FIELDPRINT process 3 times for new employees; however, on one of these 3 occasions the field print report indicated the employee had canceled the appointment, the fingerprints were not taken and thus not sent – – when in fact none of these things were true and the letter declaring that employee eligible did arrive shortly thereafter. This indicates a 33% failure rate for accurate reporting which would not be as serious an issue if you are able to obtain corrections; however, customer service at FIELDPRINT has not been amenable to contact or corrections – leaving us with an employee who has a letter stating their eligibility from DBHDS but unable to meet the verification requirement listed in the proposed manual. This should not be a surprise, since FIELDPRINT gets paid the same whether the appointment is kept and reported accurately or not, leaving them with no incentive whatsoever to accurately report or make corrections once an accurate report is identified under the current required system.

Recommendations: several avenues which could address this concern 1) return to the old system giving the ability to meet this requirement back to the provider, 2) replace FIELDPRINT with a more reliable provider of the services, 3) remove the requirement to retain documentation that the fingerprints were “taken/sent” and allow the letter of eligibility from DBHDS to meet the requirement (which presumably does document the requirement was met or they would have no basis for issuing a letter) and/or 4) require FIELDPRINT (with penalties for noncompliance) to provide more reliable customer service options to obtain corrections when they are in error (but again this with leaves the provider no recourse if they reverted back to their current way of doing business or refused to make the correction).

Developmental Disabilities Waivers – Chapter 4 page 153 & 175; Chapter 6 page 12 - Review/submission of quarterly report within 10 calendar days – In the updated DBHDS licensing regulations that went into effect August 2020, section 12 VAC 35 – 105 – 675 changed the submission deadline for quarterly reports to 15 calendar days. This additional latitude was welcome relief for many of the significantly increased onerous administrative burdens now faced by providers and there were no clear objections to the change in the comments posted during the regulatory review period for the regulation when it was proposed. However, the DMAS manual posted for comments appears to retain the 10 day deadline for review/submission of quarterly reports, which would supersede the states relaxed requirement, making it moot, as the 10 day deadline would still be required to be in regulatory compliance. As the change in the state deadline makes clear the 10 day requirement was an arbitrary number with no clear rationale for its inclusion. Specifically, the only individuals impacted by the additional 5 day relaxed standard would be support coordinators who would have less time to review provider quarterly reports turned in on the final day of the deadline. This change would not create any undue burden for support coordinators and it would provide for equal treatment between the provider and the support coordinator, as now both would have the same amount of time 15 calendar days to prepare/submit their reports (in fact on 31 day months the support coordinator would still get an extra day, that more than offsets the 1 or 2 day loss in February). In the interest of fairness, improved management of administrative burdens, regulatory consistency and equal treatment of all stakeholders in the system, it is recommended that the proposed DMAS manual changes be revised to include the 15 day deadline for review/submission of quarterly reports now enshrined in the DBHDS regulations.

Developmental Disabilities Waivers – Chapter 6 page 19 - Although I'm sure the confusion is due to my limited understanding of legalese in the regulation, I have since the inception of services 22 years ago always been troubled by the phrase that requires providers to keep records for review for "a period not less than 6 years from the Individuals last date service" and in the same section "and not less than 6 years after the date of discharge". While I assume that these statements mean we only need to retain 6 years of information on an individual at any one time, I have never been confident of this assumption and as a result have retained 18 years of records for 2 individuals that we currently and have continuously served for this length of time. As new records are generated, I would really like to shred/destroy the 1st 10 years of these records to reduce the secure/protected storage space burden created by other aspects of the regulations. However, I remain reluctant to do so because I'm not exactly sure what this phrase means------- please clarify either in the regulation or a statement of intent for the regulation.

16 Hours of work & 8 Hours of equal work Should NOT pay the SAME

Developmental Disabilities Waivers – Chapter 4 page 151 & 174 - Regulatory reliance on “a day” as the sole reimbursement unit in group home and sponsored placement residential settings perpetuates a standard that is significantly harmful to the fundamental principle of equity, individuals served in those settings and small businesses.

1. All residential service days across individuals are not equal. Significant variance will occur based on individual choices and preferences as regards employment and other day support options.

1. Many individuals will choose to avail themselves of day support opportunities which can result in some of them being absent from the home for 7 to 8 hours per day 5 days per week with others choosing programs that entail fewer hours and/or days per week. The Burns and Associates analysis in the Public Comments and Response document dated 4/23/15 – # 44, provided their official guesstimate of 26.1 hours per week in day/work programs for individuals who chose this option (this underestimates the actual time the person is outside the residential setting with these programs as it typically excludes the travel and transition time involved). Even assuming this number is accurate an individual who avails themselves of day support/work will be absent from the home (during prime support hours when they would be awake and active) for 56.55 full 24 hour days per year which represents 169.65 (8 hour shifts) where residential provider does not have to provide staffing nor supports.
2. Some individuals most of whom have prior experience with a range of day/work support options will choose not to avail themselves of day/work support opportunities and will receive plan services in the home on a continuous 24 hour basis. While there are a variety of reasons why an individual may not choose to be out of their home in a structured program during the day (retired, homebody by nature), many of these individuals choose not to avail themselves of outside day/work support opportunities because they have a strong individual preference for the staff and supports they receive in the home. Again, it is important to note that the additional hours they remain in the home are prime support hours where the individual is awake and active and any good residential provider is providing community integration, recreational/leisure, social and other plan supports consistently during these hours to individuals who remain in the home with no difference from the supports they could receive in a day support program. By choosing to allow the residential provider to meet their support needs during the day the individual is able to avoid the regimentation (set travel hours, set lunch times, set activities/schedules etc.) that is necessary and typical in structured day support programs and has much more flexibility in collaboratively achieving the community integration and other support activities they prefer to engage in if they remain in the home.

Clearly, from a residential provider perspective “a day” of support and services for an individual who chooses to be in a day/work support program and an individual who chooses not to is not equal; as the need for staffing, travel and support provision is significantly different.

2. The regulatory requirement that the “day” of these 2 individuals be treated equally for residential reimbursement is significantly harmful to the fundamental principle of equity the regulations seek to establish, individuals who receive residential waiver services and uniquely to small businesses.

1. Gross violations to the principle of equity do occur now at 2 levels:

1. Individuals served in residential programs – the SIS users manual on page 94 clearly establishes that a fundamental principle of equity to be served is that individuals with the same level of need receive the same level of funding; this is reiterated as a purpose for the regulatory changes in the introduction to the changes in the Virginia Register of Regulations 2/4/19 which claims “the same level of spending for individuals with the same level of needs” to provide for “more equitable resource distribution”. Treating the day of individuals who decline structured day/work support programs outside the home as equal to a day for those individuals who do avail themselves of these daytime opportunities creates a clear violation of the intended goal as the individual who avails themselves of daytime opportunities outside the home will receive additional funding for that day when they engage, while the individual who stays home will not receive that additional funding even though they have the exact same level of support needs. Thus, individuals with the exact same level of support needs will receive significantly different daily funding from the state; representing a gross substantial disparity each plan year; merely because they chose to exercise their right to receive their services when, where and from the provider they preferred.
2. Residential providers – treating the day of the 2 different individuals in this circumstance as equal can result in reimbursing 16 hours of awake and active supports and 8 hours of awake and active supports equally when they clearly are not – 16 hours of work should pay more than 8 hours of work; on an annual basis even using the States low guestimate this represents almost 2 months of 24 hour days on inequitably compensated work-an outrage.

2. Individuals receiving residential services are devalued and their rights are being denied at this moment due to the emergency implementation of these changes. The state devalues individuals by telling them that their day (and hence they) are not worth as much if they choose to stay home; literal as well as figurative devaluing the individual. Ironically, the introductory defense of the regulations in the Virginia Registry of Regulations 2/4/19 makes the claim that these changes “provides compliance with the CMS final rule” when in fact they create a perverse direct financial incentive to promote direct violation of their HCBS – CMS final rule rights in areas that range from their free choice of providers/ services and most importantly to their right to have control over their daily schedules. A significant number of providers (based on statements made by them at various multi provider trainings and individual served statements of their experience) directly tell individuals served in their residential programs that they cannot call out or simply choose to stay home from their day/work program, others are less open about the restriction but engage in significant “persuasion” to assure that the individuals do sign up for out of the home programs and go, some may also make acceptance into a program conditional on engaging in a day program outside; I doubt that I am aware of all the ways that some residential providers are restricting an individual’s choice as to their daily routine as regards outside of the home day program but these abuses are occurring now on a daily and routine basis. Several of the examples I am aware of directly used these regulations as the reason they could not/would not have staffing available. The financial incentive to providers to restrict individual choices is magnified when the residential provider is also the provider of the day/work support program as the current structure allows them to “double dip” into the state coffers receiving full reimbursement for the day of residential supports and additional funds for the day of work/day supports; creating an even larger financial incentive. Whether these practices are recognized/deemed important or not by the state – no one can deny given the analysis above that residential providers have a clear and perverse financial incentive to ensure individuals receiving residential services sign up for and leave the home to attend day/work programs. Since the State relies on financial incentives to achieve its other purposes how can they possibly deny that this financial incentive will create this perverse purpose.
3. Very small businesses which focus on providing exceptional residential supports are particularly disadvantaged by equal treatment of unequal days. Large bureaucratic organizations have the economies of scale, physical infrastructure and administrative hierarchy that allows him to engage in “double dipping” and as such are unlikely to protest this provision. However, very small businesses focused exclusively on residential supports have been precluded from “double dipping” by onerous licensing requirements for separate offices, staff and other barriers unless they want to become larger and more bureaucratic organizations; resulting in them shouldering the burden of unequal days with no opportunity to recoup losses. Even if these very small businesses could more easily engage in “double dipping” this would merely mean a proliferation of inbred work/day support programs that would reduce the range of providers and experiences an individual is likely to encounter; thus, reducing the advantage of separate residential and work/day programs promoted by residential only providers.

3. Preemptively, because the State does not provide any opportunity for direct rejoinder to whatever their response is to this criticism.

1. Providers have been given no opportunity to access, review nor provide rebuttal to the justification for the reliance on day as the single unit for reimbursement. These same criticisms were made in the beginning in 2014 in response to the Burns and Associates rate proposals. As is typical of bureaucratic/ political responses the specific equity, perverse incentives and small business criticisms provided here were not directly addressed in their response, rather they combine these comments with a number of others about per diem’s and set up a specious “straw man” argument they can easily address on reimbursement adequacy by pointing out that the rate structure did provide for 24 hour coverage for everyone in these residential settings and then offering support documentation and staffing flexibility as advantages of their per diem approach. Even if true this response has absolutely nothing to do with criticisms provided here the same inequity is created, the same rights are violated and very small businesses focused solely on exceptional residential supports remain uniquely disadvantaged; as The only way to meet the cost is to lower overall payroll compensation which then makes the small firm less competitive with other providers and employer types.  More importantly the inadequacy of the rate is now empirically proven as double dipper agents claimed the rate was too low for full coverage in the Richmond Times dispatch, when they lost double dipping due to corona virus closures. Additionally, these criticisms were posted in response to recent reviews of proposed DBHDS regulations and no changes were made, no rationale for the single rate was provided and the specific document criticisms listed were ignored with no response. It's bad enough that this standard is so unfair and destructive, we should at least know why it exists and why these criticisms are viewed as inaccurate and/or unimportant.
2. Correction of this gross injustice does not require a return to periodic support hours/days. Several providers I've spoken with about this concern have indicated one possible rationale may be the desire to avoid a return to the inconsistent and difficult to budget periodic reimbursement system; however, this concern could be addressed without the inclusion of periodic supports. Simply, individuals with a recent history (not counting coronavirus timeframes) of 6 months to a year of not attending any day support nor billable services outside the home, who indicate they consider themselves "retired" or for other reasons do not wish to ever receive day supports outside the home could be documented by the support coordinator at the annual meeting and they would be the eligible individuals for the increased residential support rate that would provide for equal treatment/resources with their peers who made other lifestyle choices. If the individual changed their mind and did return to a day support program the regulation could require that they revert to the old per diem rate on the day of their return to the day support program.

Recommendation – Adopt a 2 per diem rate system –the unit of service for residential programs should be bifurcated into 2 units of service each a per diem but with one representing individuals who choose to participate in a work/day support program outside the home and the other representing individuals who choose not to participate in a work/day program outside the home. Individuals who choose not to participate in a program outside the home should receive a higher reimbursement rate that would bring their reimbursement rate in line with the total daily funding of the other individuals who demonstrate the exact same level of need but do participate in outside work/day programs. This approach would retain all of the benefits claimed for the per diem by Burns and Associates while mitigating the harmful impacts. While logistics of working out an exact amount may be difficult due to the variables involved, the State seems to trust Burns and Associates and they are clearly capable given their past work of calculating the averages and variables and arriving at some defensible figure which even if it were not a direct one for one equalization in every individual case would at least mitigate the gross inequities, violation of individual rights and disadvantaging very small businesses that are occurring right now under this current structure.

XCV

Developmental Disabilities Waivers – Chapter 2 page 25 - Competency observations – While I have no concerns with the requirements for the observations of either DSP and/or advanced competencies when they apply, I do believe that one sentence in this section on page 25 requires comment. At the bottom of the page a sentence appears states "in instances where the director is also a supervisor or providing direct support, it is recommended that another supervisor not directly supervised by the director observe for competencies and sign the competencies checklist along with the director". This statement is particularly problematic for small businesses like ours whose goal is to meet or exceed any regulatory requirement or recommendation. In very small businesses like ours, where director supports and/or direct supervision of other supervisor/DSPs is most likely to occur complying with this recommendation is essentially impossible. As a very small agency we have only 2 supervisory personnel (the director and house manager) and there is no one to directly supervise the house manager except the director and thus no way to have "another supervisor not directly supervised by the director observe for competencies". While I understand that the use of the term "recommended" as opposed to required does create a loophole that would allow continued operation without any observation of director competencies, our agency (unsure how others feel) is loath to take advantage of loopholes in the provision of services and regulatory compliance. However, not taking advantage of the loophole would leave us with only 3 options: 1st – the director could discontinue providing services and supervision but that would leave the house manager without a supervisor just moving the problem one level, significantly undermine effective responses to staff callouts/shortages, take away the only part of the job I really love (never wanted to be a full-time administrator but here we are) and probably make continued service provision unlikely leading to our eventual closure; 2nd – hire an outside supervisor just for the purpose of the director competency observations but this would require complete training/retraining and ongoing hourly pay for a contractor to observe the competencies over time for the annual renewals which is currently beyond our financial abilities leading to closure and would not serve the intent of the regulatory recommendation as someone would have to supervised contractor and that someone would be supervised by the director just creating an additional layer between but not eliminated the conflict of interest the regulatory language appears designed to address. Again, I have no specific recommendations for change and feel we could continue to operate were this regulatory language included in the final document; however, as written it cast very small businesses who are unable to comply with the recommendation under a negative cloud, creates a circumstance where they may be arguably accused of not meeting best practices as recommended in the regulations and would be utterly devastating forcing closure of many small businesses if it were ever to be made into a requirement; thus warranting reconsideration for inclusion as written.

Chaper IV p.53:

"Only the actual cost of material attributed to the provider of the AT is reimbursed.
Shipping, freight and delivery are not billable to DMAS or to the waiver individual, as such
charges are considered all-inclusive in a provider’s charge for the item(s),"

I am unsure how we as an AT provider can continue to provide this service if we cannot be reimbursed for shipping costs.  

Through the years there has been a focus on conflict free case management.  SC's can not work as DSP as an example.  I would like someone to explain then how a residential provider can become guardian to an individual living in their group home? 

In the manual on page 78, that it is important for SC's to support people in having a voice to express their preferences in services, providers and plans, even when they have a substitute decision maker. 

Providers are becoming guardians without the SC's knowledge, it is shared after the fact.  I would think the guardianship process should include talking with SC and should also be conflict free. 

Fairfax- Falls Church Community Services Board agrees and supports the comments/feedback below:

1. Chapter 4, Covered Services and Limitations-Page 36:

Criteria/Allowable Activities

A person who receives support coordination services must have a person-centered Individual Support Plan (ISP) in effect which requires at least a monthly direct or individual-related contact, communication or activity with the individual, family / caregiver, service provider(s), or significant others, including at least one face-to-face contact with the individual every 90 days. A 10 day grace period is permitted for the face-to-face contact; however, if the grace period is used, it does not change the original 90 day due date.

• Comments/feedback: Fairfax-Falls Church Community Services Board supports the proposed change to allowing a 10 day grace period for a 90 face-to-face contact.

2.  Chapter 6, Quality Management and Utilization Reviews-Page 18

Required Documentation            

Documentation will be maintained in accordance with applicable statutes and policies. Waiver services that fail to meet DMAS criteria are not reimbursable. Reimbursement is not permitted in the following situations (not an all-inclusive list): · Service authorization not obtained and/or not available at DMAS’ request; · Request for service authorization not submitted by the provider; · Patient pay requirement for the individual, but not indicated on CMS-1500 and paid by DMAS; · The provider does not meet the qualification criteria; · The provider staff’s personnel files fail to verify that the minimum qualifications outlined in Chapter II are met; · The individual resides in a nursing facility (NF), an ICF/IID, or a hospital; or · Duplicate hours or units are billed.

• Comments/feedback: Further guidance is needed around the billing process for targeted case management when an individual’s services have been interrupted due to a hospitalization/and or nursing home admission. 

3. Chapter 4, Covered Services and Limitations- Page 31

Discharging an Individual from DD Waiver Services

DMAS and DBHDS will ensure only eligible individuals receive DD waiver services and will remove the individual from the waiver and close all services when the individual is no longer eligible for the waiver. Discharge from the DD Waivers must occur when: · The individual's health, safety, and welfare and medical needs can no longer be safely met in the community, · The individual is no longer eligible for either Medicaid or no longer meets the ICF/IID level of care or diagnostic eligibility, · The individual was eligible for one of the waivers and accepted a waiver slot but did not start services for five months, · The individual moves to another state, · The individual declines DD waiver services, · The individual enters an ICF/IID, NF, or rehabilitation hospital, · The local department of social services determines that the individual is no longer financially eligible, · HCBS are not the critical alternative to prevent or delay ICF/IID placement, · An appropriate and cost-effective ISP cannot be developed, · The individual is deceased.

• Comments/feedback: Clarity is needed regarding on the timeframe when an individual should be discharged from DD waiver services, due to not finding a provider who can support their behavioral/ and or medical needs.  

1. Chapter 2 Comments:
   1. Referring to the Minimum Elements of Person-Centered ISP
      1. Comment: is this the responsibility of the Support Coordinator or the Private Provider
2. Chapter 4 Comments:
   1. Skilled Nursing (SN) service means nursing services that are provided by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) in the form of intermittent care, up to, but not to exceed 21 hours per week as detailed in the individual’s ISP.
      1. Comment: While this isn’t common, we could have a short-term situation that may support 21+ hours a week to maintain the least restrictive environment. Please consider allowing this for short term situations.
   2. Skilled Nursing - Documentation of the Physician or Nurse Practitioner orders must be completed every six months. This means that the CMS 485 and the individual plan for supports related to SN services must be updated every six months.
      1. Comment: This process is already very tedious, and we have ongoing challenges with receiving orders from Physicians and Nurse Practitioners in a timely manner. Our nurses spend significant time calling and faxing physicians. Changing this to every six months creates an even greater burden on an already overworked and underfunded nursing workforce.
   3. The annual updates to the plan for supports and every time supporting documentation is updated, the update must be reviewed with the individual and family member/caregiver, as appropriate, and such review must be documented, either by the individual and family member/caregiver's signature on the review, or a progress note describing the discussion.
      1. Comment: Can you please clarify what “supporting documentation” is?
   4. All Services: The content of each review must be discussed/reviewed with the individual and family member/caregiver, as applicable and submitted to the Support Coordinator within 10 calendar days following the end of each quarter. The discussion must be documented either by the individual and family member/caregiver's signature on the review or a progress note describing the discussion.
      1. Comment: Participation and signatures can be challenging to capture. This process has potential to delay the ten-day due date. Could we please have 30 days for the discussion/review to take place?
3. Chapter 6 Comments:
   1. Documents cannot be signed electronically by anyone other than the individual required to sign the document
      1. Comment: Please clarify as we do have other persons involved sign the document
   2. There must be evidence that person-centered reviews for the waiver services are completed and sent to the support coordinator/case manager no more than 10 days following the end of each quarter as determined by the effective start date of Individual Support Plan. However, the original person-centered review due dates remain unaffected by the date the review is completed.
      1. Comment: Will uploading to WaMS suffice as evidence of timeliness or do we have to download a copy of this evidence to our electronic health record (EHR)? This consumes space in our EHR, and we would prefer to use WaMS as our evidence.

I am writing to provide comments on behalf of the Virginia Board for People with Disabilities (the Board) regarding Virginia’s Draft Development Disabilities Waivers (BI, FIS, CL) Services Provider Manual, Chapter 4. The Board appreciates the opportunity to provide input on the manual. The Board offers the following recommendations to improve and clarify the DD Waiver provider manual, by service area.

Chapter 4: Covered Services and Limitations

Chapter 4 DD Waiver Manual Table of Contents:

This comment is specific to the chart identifying different service options in the DD waiver at the beginning of the manual. In the chart Individual and Family Caregiver Training is checked as an available service in the BI waiver, however, this service is only available in the FIS waiver. The FIS waiver versus BI waiver should be checked in the chart.

Chapter 4 DD Waiver Manual Table of Contents:

This comment is specific to the chart identifying different service options in the DD waiver at the beginning of the manual. In the chart Workplace Assistance is checked as an available service only in the FIS waiver, however, this service is also available in the CL waiver. The CL waiver should also be checked in the chart.

Diagnostic Eligibility, page 2, paragraph 1: 

This paragraph states “An individual from birth to age nine, inclusive, who has a substantial developmental delay or specific congenital or acquired condition may be considered to have a developmental disability without meeting three or more of the criteria described in (1) through (5) above if the individual, without services and supports, has a high probability of meeting those criteria later in life.”

Comment: The reference to “(1) through (5) above” is confusing because the information being referred is provided bulleted versus numbered. For clarity you may want to use numbers versus bullet points if this description is maintained.

Slot Assignment – Community Living and Family and Individual Supports Waivers, page 12:

Comment: The Critical Needs Summary (CNS) acronym should be identified before it is used.

Slot Assignment – Building Independence Waiver, Pg. 14:

Second paragraph: “When a waiver slot becomes available through attrition, DBHDS will work with the region to determine if there is an individual appropriate for the slot in the region. If not, DBHDS will reassign the slot to region with individuals who have requested access to a more integrated, independent living arrangement than can be supported through the provision of a minimal level of support (i.e., through the BI waiver).” 

Comment: Should the word “than” be “that”?  Since the BI waiver provides a minimal level of support, than is not consistent with the context.

Service Authorization, page 20, sixth bullet point on this page:

From the manual: “DD waiver services may not be authorized or reimbursed by DMAS for an individual who: “Is an inpatient of a hospital, nursing facility, ICF/IID, or inpatient rehabilitation facility.”

Comment: Under sections 1915(c), (i), (j), (k) or section 1115 demonstrations consistent with section 3715 of the CARES Act, states can provide HCBS in acute care hospitals as long as the services provided are not duplicative of services available in the hospital setting. Does DMAS intend to add this flexibility to its waiver applications with CMS?

Waiver Required Assessment, starting on page 24, comment specific to page 26 of this section:

Page 26 first paragraph: “Specified affirmative responses to the items in a through d above require a review of the individual’s record for verification. After such review, the individual may be assigned to Level 6 (Intense and Significant Medical) or Level 7 (Intense and Significant Behavioral) regardless of scoring on other sections of the SIS.

Comment: It is not clear what “items in a through d above” is referring to? Bullet points are used in the section above versus lettering.

Individual Eligibility for ID/DD Targeted Case Management (Support Coordination), page 34, second paragraph:

“Any individual who meets the above diagnostic and general Medicaid eligibility criteria for there is an individual support plan (ISP) in effect that requires direct or individual-related contacts or communication or activity with the individual, the individual's family or caregiver, service providers, significant others, and others including at least one face-to-face contact with the individual every 90 days is eligible for ID support coordination.”

Comment: There seems to be something missing from the bolded text. Should “for” be “and”?

Assistive Technology, Service Units and Service Limitations, pages 51 and 53:

Page 51, “The service unit is always one, for the total cost of all AT requested for a specific timeframe. The service unit is the total cost of the item and any supplies, or hourly Rehabilitation Engineering costs,”

Comment: It may be helpful to include “freight” as an example of allowable cost when determining the total cost of all AT. How the freight cost is recouped by the provider is often an area with questions and concerns.

Page 53, “Only the actual cost of material attributed to the provider of the AT is reimbursed. Shipping, freight and delivery are not billable to DMAS or to the waiver individual, as such charges are considered all-inclusive in a provider’s charge for the item(s),”

Comment: Stating that shipping, freight and delivery is not billable to DMAS can be misleading as DMAS allows these costs to be included as part of the total cost of the AT. DMAS has provided this guidance to providers and it should be clarified in the manual so that providers fully understand what is and is not allowable.

Community Guide Services, documentation requirements, page 59:

Third bullet: “Written documentation in the form of unique, person-centered, progress notes or data collected in a supports checklist as appropriate, per the plan for supports. This documentation must confirm the individual's days in service to support units of service delivered and provide specific information regarding the individual's responses to various settings and supports, as well as specific circumstances that prevented provision of the scheduled service, should that occur. Observations of the individual's responses to the service must be available in at least a daily note.”

Comment: The sentence stating that observations of individual’s responses to the service must be available in at least a daily note is confusing. Community Guide services are not provided on a daily basis. As such, requiring at least a daily note is not realistic.

Peer Mentor Supports, page 73 and page 112, Documentation in the form of, third bullet:

“All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS,”

Comment: Something seems to be missing from the bullet point above. In other areas of the manual with a similar documentation requirement it reads “All correspondence with the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.” Perhaps “to” should be “with” on page 73 and on page 112.

Transition Services, page 74, Allowable costs, first bullet:

“Security deposits and the first month’s rent that are required to obtain a lease on an house, condo, apartment or other residence,”

Comment: Typo, “an” should be “a”.

Transition Services, page 74, first paragraph; page 75 last paragraph:

Page 74

“Individuals may receive Transition Services through the Community Living, Family and Individual Supports, or the Building Independence waivers. Individuals who leave a qualifying facility, such as Nursing Facility (NF), Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), Institute for Mental Diseases (IMD), Psychiatric Residential Treatment Facility (PRTF), Long-Stay Hospital (LSH), or Group Home and demonstrate a need for Transition Services have 30 days after transitioning from the qualifying facility (from discharge date) to apply for Transition Services.”

Page 75:

“Transition services are not available to individuals exiting an acute care hospital. Transition Services may be authorized for a maximum of nine (9) months by the DMAS service authorization contractor prior to providing services. The funds are not available to the individual after the conclusion of the nine (9) month authorization period of time. Transition services may be requested up to two months prior to discharge. Authorization must be obtained within 30 days of discharge from the qualifying facility. If not requested within that time frame, the individual will not be considered for transition services.”

Comment: Page 74 states that an individual has 30 after transitioning to apply for Transition Services. Page 75 states that service authorization must be obtained within 30 days of discharge. It’s unclear the difference between applying for Transition Services and receiving service authorization. We recommend consistent language be used in both paragraphs to avoid confusion.

Chart at the top of page 78, page 90:

Comment: We like the chart, it is a good visual. Consider doing something similar for all services.

Benefits Planning, page 93:

“ABLEnow. Description: Work with and on behalf of the individual and family, if applicable, to open an ABLEnow account to assist the individual pay for various expenses related to maintaining health, independence and quality of life.”

Comment: Typo, we believe “to” should come after individual in the above text.

Community Engagement, page 102, Criteria/Allowable Activities:

“In addition, group day service is available for individuals who can benefit from the supported employment service, but who need group day service as an appropriate alternative or in addition to the supported employment service.”

Comment: We believe the reference to supported employment service in this section is an error and should read community engagement service.

Community Engagement, page 104, Allowable Activities:

Bullet point states “Development of living skills,” is an allowable activity.

Comment: Should this be the “Development of independent living skills.”

Bullet point typo, “Access to and utilization of public transportation and so as to develop the ability to achieve the desired destination,”

Comment: “and” should be deleted after public transportation.

Group Day Services, Service Definition/Description, page 112:

“This service is typically offered these services in a non-residential setting. Group day is a tiered service for reimbursement purposes.”

Comment: Typo, “these services” should be deleted from the above text.

Individual Supported Employment, page 119:

The description of allowable activities for ISE seems similar to the activities for Customized Employment. It is not clear how the components of Customized Employment are distinguished from the general ISE activities. A recommendation that ISE follow the model of Customized Employment for individuals who would benefit from tailored job activities would be helpful and consistent with best practice.

Workplace Assistance, page 124:

P. 124, “Workplace assistance must not be work skills training that would normally be provided by a job coach, such as supporting the individual in learning the components of the job. Instead the service is designed to help the individual who as learned the basic skills of the job maintain community employment.”

Comment: Typo. It should likely read “to help the individual who has learned the basic skills of…”

Group Home Residential, page 150

 “Group home settings larger than six licensed beds which became DD waiver providers prior to May 1, 2021 may continue to operate and receive Medicaid reimbursement.”

Comment: Regulation 12VAC30-122-390 says “March 31, 2021” for the May 1, 2021 provided in the manual.  

Supported Living, page 176

“This denotes a location in which the individual receiving support services would typically be required to move from the location in order to choose a different provider for the type of services provided in that setting, since the site is leased or sublet to the individual by the provider-owner and continuation of supports at that site is dependent upon receiving services from the provider-owner.”

Comment: The interpretation written in the manual conflicts with DBHDS staff’s interpretation that the DD waiver regulations allow an individual to retain and exercise tenancy rights while using Supported Living Services. This conflicts with plan to allow use of SRAP for Supported Living services.

Independent Living Services, page 155

Individuals generally receive up to 21 hours of IL supports per week (Sunday through Saturday) in the individual’s home or community settings. Because this service is billed on a monthly (or partial month) basis, if the individual does not receive the full 21 hours one week due to a documented reason (e.g., vacation, hospitalization, illness, refusal), additional hours may be provided, if the individual has a documented need, another week in the month.

Comment: We suggest clarifying that the limitation of 21 hours per week is based on the rate model rather than a cap in regulation.

Shared Living, page 164

To increase provider awareness, VBPD recommends adding that Transition funds may be available to an individual moving into their own home. Additionally, we recommend emphasizing that siblings and other family members without legal responsibilities to the individual may be roommates in Shared Living.

Personal Assistance: Agency-Directed and Consumer-Directed Services, page 189

Page 189 of the draft manual describes Exemption of Nurse Delegation Requirements in the CD Model.

For CD services, the Code of Virginia § 54.1-3001(12) states: “any person performing state or federally funded health care tasks directed by the consumer which are typically self-performed for an individual who lives in a private residence and who, by reason of disability is unable to perform such tasks but who is capable of directing the appropriate performance of such tasks” is exempted from the Nurse Practice Act and nurse delegation requirements.

Key requirements for the exemption from nurse delegation requirements, which must be performed in accordance with 18VAC90-19-240 through 18VAC90-19-280

· Applies to consumer-directed services only,

· Applies to tasks that are “typically” self-performed,

· The individual receiving service must be capable of directing the attendant in the appropriate performance of the task,

· The individual must live in a private residence,

· The individual must be unable to perform the tasks due to a disability.

Comment: The VBPD recommends that DMAS follow the key requirements for the exemption of nurse delegation and allow a provider of CD personal assistance services to support the prescribed use of medication, including assistance with medication administration,  in cases where the medication would normally be self-administered by the individual but for their disability (for example, placing pill-form medicine on an individual’s tongue, support with the use of a metered-dose inhaler).  

Some states, such as Louisiana, refer to such support as “Self-Guided administration of medications” and describe it as follows: The client may not physically be able to self-administer medications or perform other health care tasks for themselves but can accurately guide the worker through the process to do it for them. The role of the worker in client guided care is limited to performing the physical aspects of health care tasks such as administration of medication under the guidance of the client for whom the tasks are being done.

The Nurse Practice Act explicitly exempts this type of support, and it is allowable under the key requirements detailed in the manual. If an individual receiving CD personal assistance services is capable of directing the attendant in the appropriate performance of self-guided administration of medications, they should be able to do so as part of the personal assistance service. Not allowing such support effectively excludes many people from CD services who are otherwise capable of directing their health care tasks as described in the NPA. It is a barrier to full participation in community life, achieving greater independence, and self-determination. 

Consumer Directed Services and Service Facilitation, page 204

The support coordinator must document in the individual's record that the individual will serve as the EOR or that there is a need or desire for another person to serve as the EOR on behalf of the individual.

Comment: We recommend that the manual clarify that EORs (including those other than the individual receiving services) should be assessed for their ability to fulfil EOR responsibilities using DMAS Form 95-A. This can be clarified in the documentation referenced in the above sentence.

The Board looks forwarded to continuing to work with DMAS, DBHDS, and other stakeholders on the HCBS services system. Thank you for the opportunity to provide input.

Chapter 2

Core Competency Requirements:  Pages 21 -22 do not specify that staff providing Individual and Group Supported Employment services require the DSP competency trainings; however, the DHBDS Direct Support Professional (DSP) and DSP Supervisor DD Waiver Orientation and Competencies Protocol issued in Mach 2020 indicates that these employees are no longer excluded from this requirement.  If this is still the case, recommend including this information to improve consistency, or state that this training is not required for the purposes of billing DMAS.

Chapter IV

Supported Employment:

The list of Allowable Activities for Individual Supported Employment (but not Group SE) includes development of work-related skills such as use of community resource, break areas, and transportation systems.  Regarding the 25% intervention-to-client work hours indication, individuals who receive this funding typically have a higher level of needs.  Therefore, setting a maximum of 25% may not provide the appropriate levels of support in an individualized service delivery approach.  This can be compounded by reductions in work hours being offered, secondary to increases in minimum wage.  The hours of work offered by employers should not be used to detract from meeting the needs of individual; please reconsider this.

Service Unit information does not specifically mention Customized Employment.  Please clarify that this, too, bills at an hourly rate, as it is a form of ISE and bills according to the DARS fee schedule.

Group Home Residential:  Page 153 specifies, “Each quarterly review will represent the quarterly data however, the fourth quarter will provide an annual summary in addition to the fourth quarter data.”  Most, if not all, other services do not have this additional requirement for the fourth quarter data; rather the “Four written reviews span the entire ISP year.”  As each quarterly review is to be provided to the Support Coordinator, there is no additional benefit to the individual or the team indicating a need to single out Group Home Residential for this additional documentation and inherent administrative burden.  Please rephrase so that expectations for this service are in alignment with the established standard.   

Chapter VI

General Requirements:  Setting establishing a requirement that “If more than one service is provided, the record will be divided by service” does not take into account the framework of electronic health records and the underpinnings of data in those records.  Providers of multiple services are generally larger and more likely to already be documenting in an electronic health record.  The later point is of particular relevance to CSBs, which must submit data pulled from those records to DBHDS.  While documentation should be easily identifiable as being germane to a particular service, it is not realistic or appropriate to have distinct records when one individual receives multiple services.  This is inconsistent with DMAS’ approach to other (e.g., behavioral health) services, where there is clear recognition of shared access to information.

Assistive Technology (AT) is an HCBS waiver benefit that all recipients of DD waivers and CCC+ waivers are equally entitled to access in accordance with regulations at 12VAC30-122-270. Although there is only one regulation for AT, guidance for administration of it is inconsistent. AT requests for people with a DD waiver are approved by DBHDS according to the DD Waiver Manual Chapter IV and AT requests for people with the CCC+ waiver are approved by the MCO or KePRO according to the Durable Medical Equipment (DME) and Supplies Manual Chapter IV. Review of both manuals find extensive differences and variations, and both manuals are more restrictive than the AT regulations they are purported to clarify.

These contradictions and inconsistencies represent the root causes of many of the barriers individuals, providers, and DMAS are experiencing as reported by the HB2197 working group that DMAS was charged with hosting to identify barriers to accessing AT and related services as well as options for removing them. Making the administrative manual changes recommended below will remove many of these barriers that impact over 30,000 people with disabilities. Only the DD Waiver Manual is open for public comment; the DME Manual was closed in June 2021 after receiving zero comments. We strongly urge DMAS to revise both Manuals to appropriately reflect the AT regulations at 12VAC30-122-270 in order to remove many systemic barriers to assistive technology access. Suggested revisions for both manuals are provided below.

DD Waivers Manual, IV, Assistive Technology

Regulations 12VAC30-122-270

• Pg. 49, “Assistive technology devices are portable and authorized per calendar year” is inconsistent with the regulations, which do not require AT devices to be portable.
  • Recommend deleting “are portable and” to retain the calendar year portion of the sentence, which is consistent with the regulations.

• Pg. 50 lists allowable equipment and activities that may include a limited list that does not fully reflect the allowable scope of AT in the regs because it lists both types of AT and purposes of AT. Specifically, the allowable list in the manual does not reference AT that enables an individual to actively participate in other waiver services. This purpose of AT is referenced in both the regulations and in the manual on the previous page that lists what AT is supposed to enable. Furthermore, CMS guidance permits lists of allowable items to be used for administrative purposes only, but not to deny items that are not on an allowable list (reference DeSario letters).
  • Recommend replacing the allowable equipment and services list on page 50 about the types of allowable AT to, “Allowable equipment and activities may include specialized medical equipment and ancillary equipment; durable or nondurable medical equipment and supplies; adaptive devices, appliances, and controls; and other equipment, devices, items, and software that meets the service definition.”

• Pg. 51 is a stand-alone exclusion that is neither supported by the regs nor referenced in the allowable items section of the regs or the manual, “Items such as furniture shall not be approved if they are of general utility and are not of direct medical benefit.” The regulations require an independent professional consultation that should determine on its own merit if the AT is needed to, “enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, or to participate in other waiver services. (12VAC30-122-270),” in order for the AT to be approved, making this additional stipulation unnecessary.
  • Recommend deletion of the entire sentence.

• Pg. 51 about software compatibility is more restrictive than regulations, “AT providers must ensure that requests for software are compatible with the individual’s current computer.” This assumes all individuals have a computer at all, let alone one that is compatible with every type of software that might be evaluated as necessary AT by an independent professional’s recommendation. The regulations are clear that the independent professional shall determine the most appropriate item(s) for the individual’s needs, which may be compatible with a device that they already own or may require upgrades, enhancements, or a separate device.
  • Recommend deletion of the entire sentence.

• Pg. 51 under Service Units and Service Limitations, first bullet, “for a specific timeframe” does not clarify the implementation of the regulation. The only timeframe specified in the regulations at (12VAC30-122-270) is the budget limit for a calendar year, and many prior authorization systems only accept a 1 month service period for the AT code used for service authorization requests.
  • Recommend either deleting “for a specific timeframe” or revising to, “for the timeframe specified by the service authorization system.”

• Pg. 52 under Service Units and Service Limitations bullet about AT under EPSDT for children is vague, confusing, and is more restrictive than the regulation. The regulation at (12VAC30-122-270) C.4. Service units and limitations says, “Requests for AT service via a DD Waiver shall be denied if the AT service is available under EPSDT.” Nowhere in any of the regulations are children under 21 limited to only AT available under EPSDT. Instead of instructions and guidance about how to coordinate the AT benefits that children are eligible to receive under both EPSDT and HCBS in order to comply with the regulation if the requested AT is not available to the child under EPSDT, the proposed manual language only says, “AT for individuals younger than 21 years of age must be accessed through the EPSDT benefit,” indicating children may only access AT under the EPSDT benefit.
  • Recommend revision: “AT for individuals younger than 21 years of age may be requested via a DD Waiver if the AT is not available to the child under EPSDT.”

• Pg. 52 Service Exclusions first bullet assumes all of the items listed will only ever be for the purposes of convenience, restraint, or recreational or leisure purposes. This administrative declaration circumvents and undermines the fundamental requirement for an independent, professional consultation/evaluation, and could restrict individuals from accessing the least expensive, most cost-effective manner of meeting the regulatory purpose of AT, “to enable individuals to increase abilities to perform ADLs; to perceive control, or communicate with their environment; to actively participate in other waiver services; or are necessary for the proper functioning (12VAC30-122-270)” of other equipment. As drafted, the manual permits service authorization staff to overrule the independent professional if any item related to those excluded, regardless of compliance with the regulations. Blanket exclusions are unnecessary and contradictory to the several pages of criteria, guidance, exclusions, and instructions in the manual that safeguard the AT fund for appropriate and compliant utilization.
  • Recommend deletion of the entire first bullet.

• Pg. 53 last bullet under Service Exclusions was just copied from the regulations into the draft manual without any additional explanation or guidance. It is about duplication of payment for services that are reasonable accommodation requirements of the ADA and other Acts. What constitutes a duplication of payment? If an AT service is otherwise paid by whom? The HCBS AT budget? The Waiver? A Waiver provider? The State Plan? Another State entity? If the individual already has the AT that provides reasonable accommodation, then the independent professional would not recommend it as a needed item. Please describe a real-world example of a duplicate waiver payment for AT that supports this restriction.
  • Recommend revision with example that provides a better understanding of the regulation.

• Pg. 54 bullet under Provider Documentation Requirements says, “Documentation in the Support Coordination record of notification by the individual or individual’s representative family/caregiver of satisfactory completion or receipt of the service or item.” This is supported in the regulations but is not a requirement that the AT provider can fulfill.
  • Recommend removing this bullet from the Provider Documentation Requirements and consider adding a separate Support Coordinator Requirements list and/or adding it to the Support Coordination Manual also currently open for public comment.

• Pg. 54 last bullet under Provider Documentation Requirements is for the “Support Coordinator to perform and document a face-to-face visit to assure that the individual can use the AT safely and appropriately.” This is not a requirement for provider documentation and is not supported in the regulations at (12VAC30-122-270). The other documentation requirements listed in the manual are copied from the regulations without additional detail or guidance, but this particular bullet does not reflect any requirement in the regulations for a face-to-face visit or assurance of safe and appropriate use. Only a professional trained in the AT item could make an assurance that the individual can use the AT safely and appropriately, which is part of the required independent professional consultation/evaluation.
  • Recommend deletion of the entire sentence.

Durable Medical Equipment and Supplies Manual, IV

Regulations 12VAC30-122-270

• Pg. 27, “All assistive-technology equipment must be medically necessary and essential for the treatment of illness or injury,” which contradicts the regulatory definition of AT that differentiates AT from DME where DME treats illness or injury and AT enables personal functioning, “enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, or to participate in other waiver services. (12VAC30-122-270)” AT regulations don’t require items to be medically necessary or essential, and do not require treatment of illness or injury, “to increase his ability to control his environment, support ISP outcomes as identified, and live safely and independently in the least restrictive community setting. (12VAC30-122-270)”
  • Suggested deletion and revision, “Assistive-technology equipment includes, but is not limited to, adaptive utensils, wall-mounted insulin delivery devices, and automatic feeder systems, and other technologies needed in any setting to increase the individual’s ability to control his environment, support ISP outcomes as identified, and live safely and independently in the least restrictive community setting. All assistive-technology equipment must be medically necessary and essential for the treatment of illness or injury.”

• Pg. 27, “Assistive technology equipment does not include… items that are not for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body part…” This directly contradicts the regulatory differences between DME and AT where DME treats illness or injury, and AT enables personal functioning, “enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, or to participate in other waiver services. (12VAC30-122-270)” AT doesn’t have to diagnose or treat a condition or malformed body parts.
  • Suggested deletion of the phrase, “items that are not for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body part;.”

• Pg. 27 includes a reference, “(12 VAC 30-50- 165)” that is irrelevant to AT. It refers to a requirement for DME to be suitable for use in the home, which directly contradicts the AT regulations that permit the use of AT in any setting, “in the individual's primary home, primary vehicle, community activity setting, or day program,” and “in the least restrictive community setting (12VAC30-122-270).”
  • Suggest deleting “(12 VAC 30-50- 165)”.

• Pg. 27 states that AT must be approved under individual based outcomes or supportive activities to accomplish outcomes, “The following conditions must be met for DMAS to approve reimbursement of assistive technology equipment. Approval may occur under one of the following categories,” where at least one of two criteria must be met for individual-based outcomes, or all criteria must be met for supportive activities to accomplish outcomes. These stipulations are more prescriptive than and contradictory to regulations. Including these conditions in the administrative manual will permit MCOs to deny literally all AT requests. Furthermore, CMS guidance permits lists of allowable items to be used for administrative purposes only, but not to deny items that are not on an allowable list (reference DeSario letters).
  • Suggest deletion of, “Approval may occur under one of the following categories:” and making revisions to the “categories” as suggested below to remain compliant with the regulations at 12VAC30-122-270.

• Pg. 27,  “An identified, realistic goal exists that makes necessary the use of the assistive technology equipment for the treatment of the medical condition,” or “anticipated stabilization of the medical condition or progress toward goal achievement is clearly related to the use of the equipment.” Pg. 28 details the second category that AT may be approved under, “Supportive Activities to Accomplish Outcomes (all of the following must be met).” AT regulation doesn’t require the item to meet any individual outcome, treat or stabilize a medical condition, or require the individual to have a goal that is related to the use of the AT. This guidance misrepresents the regulation entirely, which already includes detailed criteria and allowable activities; service requirements; service units and limitations; provider qualifications and requirements; and service documentation and requirements. None of those detailed regulations mention medical treatment or outcomes/goals. Instead, the regulations include, the AT item will, “support ISP outcomes as identified… enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, to participate in other waiver services. (12VAC30-122-270)”

• Pg. 28 criteria require that, “Goal(s) must be a part of an active, rehabilitative, therapeutic plan of care in place at the initiation of the use of the equipment. The goal(s) must be realistic in that it is consistent with the individual’s cognitive, environmental, and physical status,” but regulations do not limit items to therapeutic use or require a therapy plan. Only supporting needs identified in the support plan is referenced, “shall entail specialized equipment…, including those specified in the individual support plan.” AT requests require an independent consultation, “an independent professional consultation to determine the level of need that is not performed by the AT service provider shall be obtained from staff knowledgeable of that item for each AT service, (12VAC30-122-270),” not a plan of care.

• Pg. 28 criteria require that, “the individual or caregiver demonstrates the ability cognitively, motivationally, and physically to effectively utilize the equipment toward goal achievement. Someone is available to regularly assist the individual as necessary in the use of the equipment to facilitate progress toward the goal.” None of this is supported by the regulations and none of it is enforceable. How should an AT provider demonstrate that someone has the ability to motivationally effectively use the item; what happens if a caregiver doesn’t regularly assist the individual; and who determines if progress toward a goal is made, how, and when? More importantly, why is the AT provider who delivers equipment held accountable for the performance of other services and why is a single piece of equipment solely responsible for achieving progress?

• Pg. 28 criteria require, “within the plan of care, documentation exists that other equipment and/or health care alternatives have been considered and rejected as not appropriate for the treatment of the medical condition.” AT regulations do not require other equipment or alternatives to have failed to treat a medical condition before the AT request will be considered. Other equipment is only noted if a rehabilitation engineer is requested, “if an existing device must be modified or a specialized device must be designed and fabricated, a rehabilitation engineer or certified rehabilitation specialist may be utilized. (12VAC30-122-270)”

• Pg. 28 criteria exclude an individual’s eligibility for AT if they have a low energy condition, “the individual does not have a deficient level of “energy” or other systemic condition (e.g., CHF, COPD).” Anyone who has these or other chronic diagnoses that cause low energy levels could be denied for all AT requests. Regulations require an independent consultation to ensure the individual is capable of using the item. An additional administrative criteria is unnecessary and potentially discriminatory.

• Pg. 28 requires, “the equipment must reduce the need for other reimbursed health care (such as personal care, private duty nursing, rehabilitation services, and/or home health services).” This is entirely contradictory to the regulation and not supported anywhere.

Suggested Revisions for the section that begins with, “The following conditions,” through the end of the AT section on p28 of DME Manual, IV to align with DD Manual, IV and comply with AT regulations (12VAC30-122-270):

“The following conditions must be met for DMAS to approve reimbursement of assistive technology equipment. These conditions are applicable whether the equipment is for initial use or replacement. Individual use of the requested AT will enable increased abilities to: (at least one)

1. Perform activities of daily living (ADLs);
2. Perceive, control, or communicate with their environment;
3. Actively participate in other waiver services that are part of their plan for supports;
4. Be independent in areas of personal care;
5. Communicate more effectively;
6. Support of individual service plan outcomes as identified; or
7. Properly use items necessary for life support, including the ancillary supplies and equipment.

For each assistive technology request for approval, the AT provider or the independent professional shall provide documentation of:

• Recommendation for the requested AT based on a consultation not performed by the AT service provider, but rather an independent professional knowledgeable of both the requested AT and the individual’s needs that it will address.
• Applicable standards of manufacture, design, and installation, and the provider will provide all warranties or guarantees from the AT manufacturer to the individual and family/caregiver, as appropriate.
• If the AT will be initiated in combination with environmental modifications involving systems that are not compatible, or an existing device must be modified or a specialized device must be designed and fabricated, a rehabilitation engineer or certified rehabilitation specialist may be utilized.
• Not solely for purposes of convenience of the caregiver, restraint of the individual, or recreation or leisure activities.
• Not otherwise available through the State Plan for Medical Assistance.
• Used in the least restrictive community setting, which includes the individual's home, vehicle, community activity setting, or day program.

In order for an AT claim to be reimbursed, all of the following must be documented:

• Prior authorization received before delivery
• AT was received or installed and in working order
• Warranties and procedures for technical support were provided
• Individual is capable of using AT”

Chapter 2, Support Coordination / Case Management

Currently employees are not required to have a bachelor’s degree to provide ID case management but they are required to have a bachelor’s degree to provide DD case management.  We are in a current workforce shortage.  We believe employees who meet the full KSAs for ID case management are fully qualified to provide DD case management.  We recommend using the ID case management KSAs to qualify to provide both ID and DD case management.

VIDES Discrepancy

Page 3 of Chapter 4 indicates that “VIDES for infants must be used for the evaluation of individuals who are younger than three years of age.  Two or more of five categories must be met.  Vides for children must be used for the evaluation of individuals who are three years of age through 17 years of age.  Two or more of seven categories must be met.”  However, page 6 of Chapter 6 contradicts this guidance by stating the VIDES must “document that the individual meets the dependency level in two or more (for infants) and three or more (for children and adults) of the categories.” 

We recommend correcting this inconsistency in Chapter 6 to reflect the current requirements of two (2) areas for infants and children and three (3) areas for adults. 

SIS Discrepancy

Page 25 of Chapter 4 indicates:

“The SIS or other developmentally appropriate assessment is completed according to the following regular schedule:

At least every four years for those individuals who are 22 years of age and older,

At least every three years for those individuals who are 16 years of age through 21 years of age,

Every two years for individuals five years through 15 years of age. . .

For children younger than five years of age, an alternative industry assessment instrument approved by DBHDS, such as the Early Learning Assessment Profile, will be completed by the appropriate professional every two years for service planning purposes.”

However, on page 9 of Chapter 6, guidance states, “Individuals 16 years or older will have a Virginia SIS® completed every four years or more frequently if the individual has undergone significant changes and those between 5 and 15 years will have a Child SIS® completed every two years.”

We recommend that DMAS amend the Chapters to eliminate any discrepancy regarding the SIS.

Priority Needs Checklist and Critical Needs Scoring

Page 11 of Chapter 4 states, “a review of the individual’s status and a new Priority Criteria Checklist will be completed by the Support Coordinator when the needs of the individual change, but ideally no less than once every three years.”  We are seeking clarification as to the meaning of “ideally” for purposes of this sections.  Should this phrase be interpreted to offer flexibility as to the checklist completion?

Furthermore, page 11 of Chapter 4 states, “the Critical Needs Summary form for each individual on the waiting list must be reviewed and updated annually and whenever the individual’s “critical needs” change.”  We are seeking clarification on the meaning of the term “annually.”  Is this referring to annually from when the last form was completed or annually from when the individual is entered priority 1, when they went onto the waitlist?

Slot Availability

Page 13 of Chapter IV states, “the Support Coordinator must notify the individual and family/caregiver of slot availability and available services within the offered waiver within 7 calendar days of the waiver slot assignment date.”  We have concerns regarding the realistic ability for Support Coordination to meet this requirement. The requirement to notify within 7 calendar days of slot assignment is not typically an issue if there are only a few slots; however, many slots are assigned all at once, this is a challenge.  The information indicates calendar days, which does not account for holidays or weekends.  The assignment date is the date DBHDS moved the individual to “projected” status.  CSBs and Support Coordinators shall make all efforts to notify the family within 7 days; however, there must be a way for CSBs to request an extension based on emergency situations and/or number of slots assigned at once.  Additionally, the Developmental Services Director of each CSB needs to receive notification of slots assigned as a particular Support Coordinator may be on leave.

Page 13 of Chapter IV also states, “the individual or family caregiver, as applicable, will confirm acceptance or declination of the slot within 15 calendar days of notification of slot availability.”  This guidance is vague in terms of what CSBs and Support Coordinators are to do if the family does not respond within 15 days.  We are seeking guidance on actions regarding what actions to take when such situations are encountered.

General Comments

Chapter IV, page 27 and page 44, indicate no more than 365 days (or 366 days in leap year) between ISP dates and updating the ISP.  Please clarify if both refer to the plan dates rather than one being around ISP planning meetings.

The new manual indicates private duty nursing authorization for adults must be done every 6 months rather than annually.  Private duty nursing is a critical service and the administrative process associated with doing the renewals is burdensome on CSBs.  We ask that DMAS please provide information regarding reasoning for this change and ability to revisit to ensure service delivery.

We are concerned about the practicality of meeting notification timelines for initial Waiver assignments (7 days to notify families, 15 days for them to respond, 30 days for the first meeting).  Based on our public comment regarding the Waiver Regulations, we were told the manuals would provide information on requesting exceptions; however, the manual does not provide this information.  How do we proceed to request an extended timeline when 25 more slots are being assigned at one time?

DD Manual, IV pg. 61

Only one unit of service is only appropriate for equipment or items that are delivered once. Services that include ongoing monitoring and other supports delivered electronically occur periodically and routinely as needed by the individual, similar to therapeutic consultation. Please consider separating administration of EHBS coverage of equipment from EHBS coverage of services to allow for appropriate and compliant service authorization and billing for ongoing services.

DD Waiver Manual - Chapter 4 Part #1 - vaACCSES
GENERAL COMMENTS:

1. Purpose of Manual to provide explanation, clarification, definition, examples, possible service scenarios, and interpretation for providers to deliver consistent implementation of quality services, documentation and required reports across the Commonwealth. However, we have found that there are numerous items in the Manual that are more prescriptive than what is included within DD Waiver regulatory authority - which is problematic. The Manual should not be more prescriptive than regulations since the governing authority are the regs. The addition of regulatory citations would help as reference throughout the Manual as appropriate.  
2. Consistency between Regulations and Manual is critical.  There are multiple examples throughout the Manual of inconsistencies between licensing regulations, DD Waiver regulations and what’s required by DMAS in the Provider Agreement.  All of this makes it confusing for the provider and creates additional administrative burden.  It also complicates the rules for providers that provide “unlicensed services”.  Because the service is unlicensed, it makes it difficult to know and fulfill requirements that refer to the licensing regulations and/or to forms referenced.
3. Chart with “Corresponding Regulations” and BI, FI and CL columns are a helpful visual and provide clarity regarding regulation reference at the beginning of each service.  We recommend that a chart be used for all services in Chapter 4. (See page 78 as example).
4. There is an overall need to clearly delineate the responsibilities and requirements for support coordinator actions versus service provider actions.  Ideally, support coordination would either have a companion Manual or minimally, within the Waiver manual, have clear sections within chapters and/or services. Possibly, even a separate chapter with ONLY the Support Coordination requirements and responsibilities. The lack of separation and specificity are confusing regarding responsibility and requirements of “providers” throughout the Manual.  The question asked often throughout is “which provider is responsible”.
5. We request that overall instructions on how providers should round any fractions of service hours provided for billing purposes. This is not included in the current Manual but would be very helpful as an overall instruction to provide specification and consistency. In the past when we asked, we were told that these instructions were to be included in the future Manual in a chapter for “other services”.  It would of course be efficient to include this information within the Waiver manual.

CHAPTER 4:

Table of Contents & Service Option Charts:
Corrections Needed:

• Individual & Family/Caregiver Training is incorrectly marked as included in the BI waiver - should be FIS Waiver
• Workplace Assistance Services is incorrectly marked as only being included in the FIS Waiver - it is also included in the CL Waiver.

Page 1 - Criteria to Be Eligible -
Comment:  What if they do not have "functional limitations in major life activities" - but might need Companion Care or Sensory Equipment (AT or DME)?

Diagnostic Eligibility

Page 2, paragraph 1:
COMMENT:  Correction Needed. Paragraph refers to “three of more criteria described in (1) through (5) above…”  Please change bullets to numbers for clarity.

Day Assessment Service Authorization Requests

Page 22:

Comment:  Would prefer that the language used provide additional clarity than the 60-day assessment is an option (“may”) - but not required. Recommend - “Provider has the option to request a 60-day assessment prior to initiating plan for supports.”

Page 23:  Provider Discontinuation of Services.

Comment: Regarding 10 business days advanced notice in writing. This is not always possible. Individual Supported Employment (ISE) services, for example, will end when an individual quits or is terminated from a position and DARS categories are open. Would prefer language that better reflects that this is best practice when possible but not required. Additionally, it indicates that in a situation in which health/safety concerns are the reason for discharge, DBHDS must be notified – who at DBHDS is to be notified?

Assistive Technology (AT)  

General Comment: Assistive Technology (AT) is an HCBS waiver benefit that all recipients of DD waivers and CCC+ waivers are equally entitled to access in accordance with regulations at 12VAC30-122-270. Although there is only one regulation for AT, guidance for administration of it is inconsistent. AT requests for people with a DD waiver are approved by DBHDS according to the DD Waiver Manual Chapter IV and AT requests for people with the CCC+ waiver are approved by the MCO or KePRO according to the Durable Medical Equipment (DME) and Supplies Manual Chapter IV. Review of both manuals find extensive differences and variations, and both manuals are more restrictive than the AT regulations they are purported to clarify.

These contradictions and inconsistencies represent the root causes of many of the barriers that individuals, providers, and DMAS are experiencing as reported by the HB2197 working group that DMAS was charged with hosting to identify barriers to accessing AT and related services as well as options for removing them. Making the administrative manual changes recommended below will remove many of these barriers that impact over 30,000 people with disabilities. Only the DD Waiver Manual is open for public comment; the DME Manual was closed in June 2021 after receiving zero comments. We strongly urge DMAS to revise both Manuals to appropriately reflect the AT regulations at 12VAC30-122-270. Suggested revisions for both manuals are provided below.

Relevant Regs at 12VAC30-122-270.

Page 49 - Service Description - 2^nd to last sentence
Comment:  “Assistive technology devices are portable and authorized per calendar year” is inconsistent with the regulations, which do not require AT devices to be portable. Recommend DELETE “are portable and” to retain the calendar year portion of the sentence, which is consistent with the regulations.

Page 50 - Examples - Allowable Equipment Table

Comment:  Lists allowable equipment and activities that may include a limited list that does not fully reflect the allowable scope of AT in the regs because it lists both types of AT and purposes of AT. Specifically, the allowable list in the manual does not reference AT that enables an individual to actively participate in other waiver services. This purpose of AT is referenced in both the regulations and in the manual on the previous page that lists what AT is supposed to enable.

Recommend replacing the allowable equipment and services list on page 50 about the types of allowable AT to, “Allowable equipment and activities may include specialized medical equipment and ancillary equipment; durable or nondurable medical equipment and supplies; adaptive devices, appliances, and controls; and other equipment, devices, items, and software that meets the service definition.”

Page 51

Comment: This is a stand-alone exclusion that is neither supported by the regs nor referenced in the allowable items section of the regs or the manual, “Items such as furniture shall not be approved if they are of general utility and are not of direct medical benefit.” The regulations require an independent professional consultation that should determine on its own merit if the AT is needed to, “enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, or to participate in other waiver services. (12VAC30-122-270),” in order for the AT to be approved, making this additional stipulation unnecessary.

Recommend deletion of the entire sentence.

Page 51 -
Comment:  Sentence about software compatibility is more restrictive than regulations, “AT providers must ensure that requests for software are compatible with the individual’s current computer.” This assumes all individuals have a computer at all, let alone one that is compatible with every type of software that might be evaluated as necessary AT by an independent professional’s recommendation. The regulations are clear that the independent professional shall determine the most appropriate item(s) for the individual’s needs, which may be compatible with a device that they already own or may require upgrades, enhancements, or a separate device.

Recommend deletion of the entire sentence.

Page 51 - Service Units and Service Limitations - 1^st Bullet
Comment: “for a specific timeframe” does not clarify the implementation of the regulation. The only timeframe specified in the regulations at (12VAC30-122-270) is the budget limit for a calendar year, and many prior authorization systems only accept a 1-month service period for the AT code used for service authorization requests.

Recommend either deleting “for a specific timeframe” or revising to, “for the timeframe specified by the service authorization system.”

Page 52 - Service Units and Service Limitations Bullet about AT

Comment: under EPSDT for children is vague, confusing, and is more restrictive than the regulation. The regulation at (12VAC30-122-270) C.4. Service units and limitations says, “Requests for AT service via a DD Waiver shall be denied if the AT service is available under EPSDT.” Nowhere in any of the regulations are children under 21 limited to only AT available under EPSDT. Instead of instructions and guidance about how to coordinate the AT benefits that children are eligible to receive under both EPSDT and HCBS in order to comply with the regulation if the requested AT is not available to the child under EPSDT, the proposed manual language only says, “AT for individuals younger than 21 years of age must be accessed through the EPSDT benefit,” indicating children may only access AT under the EPSDT benefit.

Recommend revision: “AT for individuals younger than 21 years of age may be requested via a DD Waiver if the AT is not available to the child under EPSDT.”

Page 52 - Service Exclusions - 1^st Bullet
Comment:  Assumes all of the items listed will only ever be for the purposes of convenience, restraint, or recreational or leisure purposes. This administrative declaration circumvents and undermines the fundamental requirement for an independent, professional consultation/evaluation, and could restrict individuals from accessing the least expensive, most cost-effective manner of meeting the regulatory purpose of AT, “to enable individuals to increase abilities to perform ADLs; to perceive control, or communicate with their environment; to actively participate in other waiver services; or are necessary for the proper functioning (12VAC30-122-270)” of other equipment. As drafted, the manual permits service authorization staff to overrule the independent professional if any item related to those excluded, regardless of compliance with the regulations. Blanket exclusions are unnecessary and contradictory to the several pages of criteria, guidance, exclusions, and instructions in the manual that safeguard the AT fund for appropriate and compliant utilization.

Recommend deletion of the entire first bullet.

Page 53 - Last Bullet - Service Exclusions
Comment:  Same as regulation. Additional explanation or guidance would be appreciative. It is about duplication of payment for services that are reasonable accommodation requirements of the ADA and other Acts. What constitutes a duplication of payment? If an AT service is otherwise paid by whom? The HCBS AT budget? The Waiver? A Waiver provider? The State Plan? Another State entity? If the individual already has the AT that provides reasonable accommodation, then the independent professional would not recommend it as a needed item. Please describe a real-world example of a duplicate waiver payment for AT that supports this restriction.

Recommend revision with example that provides a better understanding of the regulation.

Page. 54 - Provider Documentation Requirements
Comment: states “Documentation in the Support Coordination record of notification by the individual or individual’s representative family/caregiver of satisfactory completion or receipt of the service or item.” This is supported in the regulations but is not a requirement that the AT provider can fulfill.

Recommend removing this bullet from the Provider Documentation Requirements and consider adding a separate Support Coordinator Requirements list and/or adding it to the Support Coordination Manual also currently open for public comment.

Page 54 Provider Documentation Requirements - Last Bullet -
Comment:  States for the “Support Coordinator to perform and document a face-to-face visit to assure that the individual can use the AT safely and appropriately.” Overly burdensome. This is not a requirement for provider documentation and is not supported in the regulations at (12VAC30-122-270). The other documentation requirements listed in the manual are copied from the regulations without additional detail or guidance, but this particular bullet does not reflect any requirement in the regulations for a face-to-face visit or assurance of safe and appropriate use. Only a professional trained in the AT item could make an assurance that the individual can use the AT safely and appropriately, which is part of the required independent professional consultation/evaluation.

Recommend deletion of the entire sentence.

Community Guide Services

Page 59 - 3rs Bullet - Documentation Requirements
Comment: States “Observations of the individual’s responses to the service must be available in at least a daily note”. Community Guide services are not necessarily provided on a daily basis.  Is this needed and realistic. Recommend deleting “daily” from note.

Electronic Home-Based Supports (EHBS)

General Comment:  The regs and the manual are aligned with one another in a way that only makes sense for equipment. In order for providers to deliver services under EHBS, the unit of service cannot be limited to only one.
Recommend Additional Language Be Added: "Only one unit of service is only appropriate for equipment or items that are delivered once. Services that include ongoing monitoring and other supports delivered electronically occur periodically and routinely as needed by the individual, similar to therapeutic consultation. Please consider separating administration of EHBS coverage of equipment from EHBS coverage of services to allow for appropriate and compliant service authorization and billing for ongoing services."

Page 63 - Service Documentation Requirements - Bullet #2
Comment:  This documentation is the requirement of the Support Coordinator and not the EHBS provider.

Individual and Family Caregiver Training

Page 70:
Indicates that contact notes, monthly notes, and quarterly reports must be completed. This is more than the regulations require.  Is also duplicative. It is also more information than is required for other services.  Other services require a quarterly review. Clarification is needed if monthly summaries are needed when there is a quarterly review being completed.

Transition Services

Page 74 Paragraph 1 and Page 75 Last Paragraph - Inconsistent language
Comment:  Page 74 includes language that an “individual has 30 days after transitioning to apply for Transition Services”.  Page 75 states that “service authorization must be obtained within 30 days of discharge.  Recommend clarification and consistent language be used to avoid confusion.

Benefits Planning
Page 90: Criteria/Allowable Activities
1^st Paragraph
Comment:  DELETE “or” before “employment status” and ADD “or need for work incentives”.

Page 94:
Paragraph 1:  Indicates that this service requires face to face contact.
Comment:  Regulations do not specify that this be a face-to-face contact.  Alternative options must be available including telehealth and virtual options. Overly prescriptive and not included in regulations.

Page 95: Mid-page - Bullet 1 -
Comment:  ADD “or is not available” after “have been explored and exhausted”.  Also, please clarify what documentation is needed to fulfill the requirement of “explored or exhausted”.

Page 95: Mid-page - Bullet 2 - Indicates there should be documentation of “All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS”
Comment:  Should also include “DSS and SSA as appropriate” for this particular service.

Community Engagement

Page 102 - Criteria/Allowable Activities
Paragraph 1 - Last Sentence
Comment:  Underlined sentence is confusing.  Should “community engagement” be substituted for “supported employment”?

Page 104 - 7^th Bullet:
Comment:  ADD “independent” before “living skills”

Group Day Services

Page 112 - Service Definition/Description
1^st Paragraph - Last Sentence:  DELETE “these services”.

Page 114:  Semi-Predictable Events
Paragraph 1:  States “The provider may request between 3-5 hours of additional “community engagement” per week that will allow the individual to choose additional community outings.
Comment:   Shouldn’t this read:  “The provider may request between 3-5 hours of additional “group day” services per week that will allow the individual to choose additional “group day” activities.  It is not clear.  If Community Engagement - then it should be included in the Community Engagement service section,

Supported Employment Services

Page 119: Criteria/Allowable Activities
Comment: 

• Recommend that bullets be entirely realigned AND be delineated between Individual SE and Group SE.
• The first sentence indicates that there is one element that is limited to ISE only. However, there are seven elements listed and are provided in GSE services. The “this element is limited…” should be at the end of the previous bullet.  It should state - “Individual job development, with or without the individual present that produces an appropriate job match for the individual and the employer to include job analysis or determining job tasks, or both. This element is limited to ISE only and is not permitted for GSE”
• Allowable activities should allow for reimbursement for collateral contacts, including Workplace Assistance if the service is provided.  
• Staff provision of transportation – need criteria for what is considered “unavailable or inaccessible” and how this is to be documented. 

• States - “For DMAS reimbursement to occur, the individual must be present, unless otherwise noted, when these activities occur:  Vocational or job-related discovery or assessment,

Supports to ensure the individual's health and safety during the hours of work”
Comment: We recommend that the above allowable activities be noted that these activities can be conducted without the individual being present.  In fact, many discovery and assessment documents are reviewed in the absence of the individual.  Furthermore, the coordination and logistics of arranging health and safety supports, such as coordination with the employment site or family members, would precede the implementation and therefore occur without the individual being present.

Page 120: Customized Employment
Comment:  There is nothing indicated in the manual regarding who may provide this service. Under DARS funded CE only ACRE Customized Employment certified specialists may provide this service – is this the expectation for DBHDS or can any ISE employment specialist provide it?

Page 120 - Job Search Planning
Comment:  the following “conduct an analysis of benefits which may be accessed through Benefits Planning” is unclear. Benefits planning is a separate service.  What is the “analysis of benefits” that is being referred to? While most employment specialists can identify when an individual would need that service, it is the role of the support coordinator to refer for the service and coordinate services.  

Page 122: Documentation of the Individual’s Ineligibility for SE Services
5^th Bullet:  States “Documentation of the individual’s ineligibility for supported employment service through DARS or IDEA, as applicable. If the individual is ineligible to receive service through IDEA, documentation is required only for lack of DARS funding. Acceptable documentation for the lack of DARS or IDEA funding would include a letter from either DARS or the local school system or a record of a telephone call, including name, date, and person contacted, documented either in the individual's file maintained by the support coordinator, on the ISP, or on the supported employment provider's supporting documentation. Unless the individual's circumstances change, for example, the individual is seeking a new job, the original verification may be forwarded into the current record or repeated on the supporting documentation on an annual basis”
Comment: We recommend that the responsibility for documenting Waiver ineligibility based on DARS or IDEA eligibility should be the responsibility of the Support Coordinator and should be indicated as a Support Coordinator responsibility instead of a provider responsibility.

Workplace Assistance

Page 124: Criteria/Allowable Activities
Comment:  ADD “This service is designed to support individuals in competitive, integrated positions for whom all options for independence in regards to appropriate job match, reasonable accommodations, and the utilization of natural supports in the workplace have been explored, exhausted and documented. This service is supplementary to individual supported employment in order to maintain stability in the workplace.”

Page 124 - Paragraph 1
Comment:  Includes a typo. Should read “has learned the basic skills…”

Additionally, there should be information under criteria indicating that natural supports and accommodations are not available for the identified support needs.

Skilled Nursing Services

Overall Comment - Page 140 - 2^nd to last bullet - There is a significant change in the Manual which is in conflict with the DD Waiver regulations regarding the period for which an authorization is completed.  The change is more prescriptive than the regulations and changes the 1-year authorization in line with an individual’s ISP year to a 6-month authorization. The Manual should not be more prescriptive than the regulations.  This places additional burden on providers. A change in this policy needs to go through the regulatory process or legislative process for full vetting.

Group Home Residential

Page 150 - Service Limitations

Comment:  Regulation 12VAC30-122-390 says “March 31, 2021” and the Manual says “May 1, 2021”  Consistency is needed between regulations and Manual.

Page 153 - 1^st Paragraph - Last Sentence

Comment:  Manual states “Each quarterly review will represent the quarterly data.  However, the fourth quarter will provide an annual summary in addition to the fourth quarter data.  This is not authorized in regulations.  Inconsistent.

Sponsored Residential
Page 175 - Last Bullet
Comment:  DELETE last sentence “Four written reviews span the entire ISP year.”  Language is not consistent with other residential services.

Consumer Directed Services & Services Facilitation

Page 203
Comment:  After the description of CD services in general, and before the beginning of what is currently on Page 204, we recommend that you add the following regulatory language in the Manual for clarification and consistency - 12VAC30-122-150, A, 2, d, e, and f

Page 204 - Bullet 1 --
Comment: Recommend clarification around whether or not the EOR must live with the individual receiving services.  Providers often get “pended” for this.  

Page 204 - Last paragraph -  After the first sentence, ADD “If the individual chooses not to have service facilitation, the support coordinator must document which family member or caregiver other than the EOR shall perform all of the duties and meet all of the requirements of a CD services facilitator.”  (VAC1230-122-150, A, 2, e)

Page 205 - Paragraph 3 - “When two individuals who live in the same home….”.  Recommend ADD “If the individual has chosen not to have Services Facilitation, then the family member or caregiver acting in that capacity will be responsible this assessment.”

Page 205 - Paragraph 4 - Recommend the first sentence to say “An individual who has chosen consumer direction may choose, at any time, to voluntarily change all or part of their services to the agency-directed model as long as he/she/they continues to qualify for the specific services.”
Comment:  For example, he/she/they may choose to move just Respite or part of the Personal Care hours to agency, while maintaining all, or a portion of their Personal Care under the consumer-directed model of service.”  Recommend the second sentence in that paragraph to read, “The services facilitator, or family member or caregiver acting in that capacity, and the support coordinator are responsible for assisting….”

Page 205 - Last bullet - If the change recommended above for Rec 1is adopted - this bullet can remain as is.

Page 207 - Paragraph 1 - This is the explanation that needs to be moved up or copied in the CD section above SF.  See recommendation #1.

Page 207 - Paragraph 3 - The second to last sentence in this part is not proper grammar. Recommend - “Transitions from the CCC Plus Waiver to a DD waiver will only occur only on the first day of a month.”  Also, the last sentence should read, “The SF, or family member or caregiver acting in that capacity, has a role to play in this process in order to ensure continuity of care.”

Page 207 - Last Section  Bullet 2 - there needs to be a space between the words "should" and "call" in the last sentence.

Page 208 - Bullet 5 - Recommend to read “For consumer-directed services, the services facilitator, or family member or caregiver acting in that capacity, must submit the Fiscal Agent Request Form to the FE/A and initiate the change in discal employer agent, if applicable, and the change from CCC Plus Waiver services to DD Waiver services.”

Page 209 - Last Bullet - Language is different from regulations - needs consistency and not more prescriptive language. The regs (12VAC30-122-500, B, 4) state “The services facilitator, during routine quarterly visits, shall also review and verify….”  The manual states “routine semi-annual visits”.  This language should be changed to match the regs. The manual should also add “or family member or caregiver acting in that capacity” to that sentence as well. 

Page 210 - Bullet 1 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must be available during standard business hours to the individual or EOR by telephone.”

Page 210 - Bullet 2 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, will assist the individual or EOR….”

Page 210 - Bullet 3 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must complete the assessments, ….”

Page 210 - Bullet 4 - Language inconsistent with regulations.  The regs (12VAC30-122-500, B, 8) state “Service facilitation service shall be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but at a minimum quarterly routine visits shall take place.”  The manual has been changed to say, “Services facilitation will be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but, at a minimum, routine semi-annual visits.” The manual should be changed to match the regs.  Also, the language “or family member or caregiver acting in that capacity” needs to be added. 

Page 210 - Last Sentence - Recommend language change to “The SF, or family member or caregiver acting in that capacity, may not be the individual enrolled….”

Page 211 - 1^st Sentence - Recommend language change to “The SF, or family member or caregiver acting in that capacity, must document….”

Page 211 - 2^nd Sentence - Recommend language change to “Should a CD employee not report for work or terminate employment without notice, the SF or family member or caregiver acting in that capacity, upon the individual’s or EOR’s request….”

Page 211 - Service Documentation & Requirements -

• 1^st Sentence - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must maintain….”
• Bullet 1  - Recommend language change to “his” to “his/her/they” in sentence, “….receipt of training on his responsibility for the accuracy….”
• Bullet 2  - Typo - "hat" should be "that"
• Bullet 3 -  What is considered a “contact”?  This needs clarification.  Also, what is considered “medical record

Page 212 - Bullet 2 -  
Comment:  Language in the Manual should match the regulations. The Manual Language is more prescriptive. The manual reads, “In a situation whereby the individual’s needs have changed significantly, the plan for supports must be reviewed by the provider.”  The regs (12VAC30-122-500, E, 3, g) state “Documentation indicating that desired outcomes and support activities of the plan for supports have been reviewed by the consumer-directed services facilitator provider quarterly, annually, and more often as needed.”  Manual pg 212, bullet 2, the sub-bullets à These sub-bullets do not exist in the regs.  Why are we being made to document MORE than what is in the regs???  Isn’t that considered more restrictive than the regs?

Page 212 - Bullet 3 - It is missing the number of calendar days in the language.  Also, there is no time limit in the regs, so any introduction of a time limit on when the review must be submitted to the Support Coordinator is more restrictive than the regs. 

Page 212 - Bullet 3 - Sub-Bullet 1 - There is no sub-bullet in the regulations.  This needs to be a dark bullet and moved to the left to align with the other bullets.  

DD Waiver Manual - Chapter 6 - 30-Day Public Comment - vaACCSES

Quality Management and Utilization Reviews

Introduction
Page 1:

• First paragraph, 2^nd sentence - who is DMAS’s “designated agent”? Recommend clarification between DMAS QMR staff and any subcontracted contractor for financial audits, etc.
• First paragraph, 4^th sentence states “DMAS conducts compliance reviews on providers that are found to provide services in excess of established norms, ..."
  Comment:  Shouldn't this be just on those that do not provide services in accordance with the regulations?  What does "established norms" mean? Language needs to be changed or definition of “established norms” needs to be provided.

General Requirements
Page 1:

• Second paragraph, 1st sentence states "DMAS participation standards and policies".
  Comment:  Shouldn’t this refer to regulations as in the following sentence?  If “standards and policies” is retained - definition or citation needs to be included.

Page 2:

• 1^st sentence - general grammar problem - comma needed following the word "individuals”.
• Second paragraph, 1st sentence - Who is "staff"?  We assume “DMAS QMR staff” in this instance.
  Comment:  Helpful to state and delineate between DMAS QMR staff and provider staff within this paragraph and others to provide clarity. Also, "staff may request licenses” - However, not all providers are required to have staff that is licensed. Add “providers and staff required to have licenses”.  Differentiate between requirements of services that are licensed and services that are not licensed regarding criminal background checks and what “documentation” is required.

• Third paragraph, 2nd sentence - Again, the requirement to be in compliance with "DMAS provider agreements and policies"
  Comment:  Shouldn’t this refer to regulations?  If “standards and policies” is retained - definition or citation needs to be included for clarity.

• Fourth paragraph, 3rd sentence - Use of the word "provider" here. 
  Comment:  Assume this means the Agency Provider and not the Personal Care provider. However, “provider” is used interchangeably for both throughout document. “Staff” is also used interchangeably throughout the document. Clarity and specificity is needed consistently.

Page 3:

• Bullet 1, 1st sentence - states "within the program's guidelines"?  Should this be "in accordance with regulations"?
• Bullet 1, 2nd sentence - Same comment as above related to the use of the word "provider".
• Bullet 1, 3rd sentence -
  Comment:  What is considered to be "the individual's record"?  Add specific reference to what record.  Is it enough to document these things in a provider’s system?  Also, what is classified as "any substantial change"?  And what specific "documentation of such change" is required? Please add specificity.
• Bullet 1, 4th sentence - Recognize that provider’s responsibility to identify “substantial changes” and inform the Support Coordinator. 
  Comment:  However, it is the Support Coordinator’s role to obtain and coordinate those services that the individual requires to remain in the community and not the provider. The "or" that follows that requirement should be replaced with "so that the Support Coordinator can obtain any other services,...."
• Bullet 3, 2nd sentence - Clarity needed.
  Comment:  Who is considered "provider staff"?  and who is the "provider agency representative"?  In the case of Service Facilitation - clarity is needed since the SF is the one both in communication with the individual AND the one responsible for the oversight of the plan.
• Manual Pg 3, bullet 3, last sentence à where should the "providers" find the remaining list of quality of supports if this is just "some" of them?  Remember, not every provider is licensed, so we are only following the regulations and this handbook.
• Manual Pg 3, bullet 4 à are we allowed to use electronic signature now?  Where did that change in the regulations?

Page 4:

• Bullet 1 - Use of "provider" again and "maintain a record"? 
  Comment:  Can that be just be in the provider’s system?  It's confusing since the next sentence mentions the forms.  So is the "record" the "form"?  Are those one and the same?  Why not use the same word for both spots?
• 1st full paragraph - "DMAS will review the provider's performance in all the outcome areas to determine the provider's ability to achieve high quality supports..." 
  Comment:  This is where that word "provider" gets used interchangeably again.  The SF writes outcomes based on the Part 3, but the outcomes are for the Personal Care Attendant to provide to the individual and not for the SF to provide to the individual.  So, who is the "provider" whose performance DMAS is reviewing? Further clarification is needed.
• General Comment on consistency - The language is now referring to DMAS.  "DMAS will review", "DMAS will evaluate", "DMAS may require".  Before, in this same document, it refers to "staff".  Consistency is needed throughout.
• 2nd full paragraph - Shouldn’t the regulations be mentioned here instead of “policies and procedures”?
• Bullet 1 - Further clarity is needed.  What exactly is meant by "periodically"?
• Bullet 5, sentence 1  - A sentence is needed to differentiate Service Facilitation and CD services from other services and their specific requirements. States "Staff" will meet with at least one individual or PCG to determine satisfaction with the provider.  Which provider is that?  The SF provider agency?  Or the PCA provider?  Not clear regarding what would be measured for SF. 

Page 5:

• Bullet 1 - why is "provider" underlined?  Who is "staff"?  Appreciate the reference to regulations vs “policies and procedures”.   
• Bullet 3  - Who is submitting this letter to these other agencies? Specificity needed.

Comprehensive and Ongoing Assessment and Planning

Page 8:  Bullet 1, sub-bullet 5 - A parenthesis is missing here.

Page 10: Bullet 3 - Why is "the waiver enrollment date" underlined?

Services are Delivered, Reviewed and Modified as Needed
Page 11:   
Comment:  Is this for all providers or specific to Case Management?  The first bullet/sub-bullet seems to speak to each service provider, but then the second sub-bullet is specific to Case Management.  Then the third sub-bullet goes back to "each service provider".  Recommend to separate and list bullets under either provider and case management for clarity

Page 12:  Main Bullet
Comment:  Sub-bullet 1 - Provide specificity in Manual. What DMAS form is to be used for the quarterly review?  There is currently no consistency from CSB to CSB on what documentation is required to be used for quarterlies.  There is also no consistency as to what has to be in that quarterly review.  Specificity would be helpful to provide consistency.

Page 13: 

• 1st sub-bullet à "All providers must be invited to the meeting and participate in the development of the new ISP annually."  Are SF required to be present at the meeting?  Service Facilitators are not compensated for this meeting and can only bill for a reassessment visit. These meetings can be up to 3+ hours.

Services Delivered are Consistent With Service Limits
Page 13:  Bullet 1, sub-bullet 2 -
Comment:  Need additional specificity for Service Facilitation - recommend separate sub-bullet. "The number of hours does require authorization."  What hours?  MT Units?  PCA hours?  Respite Hours?  Companion Hours?  The hours the SF is working?

Page 15: Bullet 2
Comment:  Paper timesheets went away a long time ago, so the EOR and employee will not be signing them.  Time is either logged via app, online portal, or by calling in using IVR.  So billing for CD services will not be supported by a timesheet that is signed.  This point in the manual needs to be removed.

Support Coordinator/Case Manager/Provider Responsibilities
Page 23:
Comment:  Need to REMOVE “Provider” from this section. “Provider” should not be included in this title when the first paragraph says that the following things are the responsibility of the support coordinator/case manager, and doesn't mention the provider?  None of the things listed are the responsibility of the provider. 

Chapter II

Pg. 34 The expectation that incumbents possess all KSA’s at time of interview/onboarding seems unrealistic in today’s workforce and does not allow for those coming from varied backgrounds, geographical areas, etc. It would make more sense to allow at least 30 days to assess these areas or allow a way to develop staff that meet most of the requirements.

Pg. 36. It seems illogical to continue the separate treatment of ID and DD populations following the merger and waiver redesign. There is also the statement that CSB’s must contract with other entities. This should read “may” and will be increasingly difficult as the number of private providers dwindle. The Support Coordinator for DD population must have  a Bachelors but this is not specified in the previous section for ID Support Coordinators. Again, inconsistent. The following pages seem to apply to only DD population but I would imagine they probably apply to both but it is very unclear and meandering in content.

Chapter IV

Pg. 1 Diagnostic Eligibility- DSM diagnosis for Intellectual Disability still specifies age of onset as prior to age 18. In this section the age of onset only specifies 22 years of age. As there are separate reimbursement rates and other considerations where differentiation is necessary between ID and DD diagnosis it seems that there are two different age parameters required.

Pg. 8 First paragraph, last sentence. In current practice DBHDS staff enroll the individual in the slot in projected status, not the Support Coordinator.

Pg. 11 Currently we are not receiving an auto-generated Notice of Action Form. The Support Coordinator sends an appeal letter generated at the CSB level.

Pg. 12 Is this new change that an individual can be presented to a WSAC without being on the wait list?

Pg. 14 First paragraph- there is another reference to the SC enrolling the individual in waiver whereas that is currently done by DBHDS staff prior to the assessment of financial eligibility.

Pg. 20 Does the Provider Part V need to be maintained in the SC’s electronic health record as it is created and/or uploaded by the provider to WaMS and resides within that system?

Pg. 33 Specifies that individuals must be Medicaid eligible to receive ID Support Coordination. Does that mean that we cannot provide Support Coordination if the individual does not have Medicaid or eligible for Medicaid? We have individuals in that situation who need services but have assets and such that make them ineligible. We would charge on a sliding fee schedule.

Pgs. 33-39 Since the waiver redesign and merger of the waivers (2016) why does DBHDS continue to specify different sets of rules for those that are ID vs. DD? In our experience they should be viewed under one set of regulations.

Pg. 40-41 Why is reimbursement available to screen DD individuals vs. ID? Again there seems to be no reason to make such a differentiation as the waivers were supposed to have merged.

Pg. 42 Why is the ISP still required to be retained in the CSB record now that the ISP is fully available and completed in WaMS?

Pg. 53 For assistive technology clarification is needed on the exclusion of shipping, freight and delivery costs associated with AT. It does not appear reasonable that any provider would supply products at cost. These additional charges are typical of any type of purchase and necessary.

Pg. 64 Removal  or disposal is not allowable for EM, but it is standard that contractors need to remove and dispose of materials during construction.

The Arc of Virginia’s Comments on DD Waiver DRAFT Manual  Nov. 11.4.2021 

The Arc of Virginia is offering the following comments on the Draft DD Waiver Manual - Chapter 4.

We appreciate the format that includes the Table of Contents for the manual, chart of services by waiver type and identification of incompatible services.

The manuals contain valuable information for those who use waiver services. If the manuals are placed on the Member Page of the DMAS website then they will be much more accessible for the users of DD Waiver.

Waiting List Priority Status and Criteria 

Priority One designates four criteria including:

“The individual is a young adult who is no longer eligible for IDEA services and has expressed a desire to live independently.  After individuals attain 27 years of age, this criterion shall no longer apply.”.

Comment:

DBHDS has added additional requirements for a person to meet this criteria. If a person meets the criteria (above) in the manual but it does not specify that there are additional requirements to meet Priority Level Onem it is misleading.

Peer Mentor  

“The peer mentor has face-to-face contact with the individual to discuss his/her specific interests/desired outcomes related to realizing greater independence and the barriers to achieving them;  The peer mentor explains community services and programs and suggests strategies to the individual to achieve his/her desired outcomes, particularly related to living more independently, engaging in paid employment and expanding social opportunities in order to ultimately reduce the need for supports from family members or paid staff;  The peer mentor provides information from his/her experiences to help the individual in problem solving, decision making, developing supportive community relationships and exploring specific community resources that promote increased independence and community integration;  The peer mentor assists the individual in developing a personal plan for accessing the identified integrated community activities, supports, services, and/or resources. 

Contacts between the Peer Mentor and the individual who is receiving the waiver may be in the form of face-to-face or remote technology that allows the Peer Mentor to view the individual and converse with him.” 

Comment: For clarity and consistency add “or remote technology” after “face to face” in this statement  ““The peer mentor has face-to-face contact with the individual to discuss his/her specific interests/desired outcomes related to realizing greater independence and the barriers to achieving them; 

We strongly support The VA Board for People with Disabilities’ comment below:

Personal Assistance: Agency-Directed and Consumer-Directed Services, page 189

Page 189 of the draft manual describes Exemption of Nurse Delegation Requirements in the CD Model.

For CD services, the Code of Virginia § 54.1-3001(12) states: “any person performing state or federally funded health care tasks directed by the consumer which are typically self-performed for an individual who lives in a private residence and who, by reason of disability is unable to perform such tasks but who is capable of directing the appropriate performance of such tasks” is exempted from the Nurse Practice Act and nurse delegation requirements.

Key requirements for the exemption from nurse delegation requirements, which must be performed in accordance with 18VAC90-19-240 through 18VAC90-19-280

· Applies to consumer-directed services only,

· Applies to tasks that are “typically” self-performed,

· The individual receiving service must be capable of directing the attendant in the appropriate performance of the task,

· The individual must live in a private residence,

· The individual must be unable to perform the tasks due to a disability.

Comment: The VBPD recommends that DMAS follow the key requirements for the exemption of nurse delegation and allow a provider of CD personal assistance services to support the prescribed use of medication, including assistance with medication administration,  in cases where the medication would normally be self-administered by the individual but for their disability (for example, placing pill-form medicine on an individual’s tongue, support with the use of a metered-dose inhaler).  

Some states, such as Louisiana, refer to such support as “Self-Guided administration of medications” and describe it as follows: The client may not physically be able to self-administer medications or perform other health care tasks for themselves but can accurately guide the worker through the process to do it for them. The role of the worker in client guided care is limited to performing the physical aspects of health care tasks such as administration of medication under the guidance of the client for whom the tasks are being done.

The Nurse Practice Act explicitly exempts this type of support, and it is allowable under the key requirements detailed in the manual. If an individual receiving CD personal assistance services is capable of directing the attendant in the appropriate performance of self-guided administration of medications, they should be able to do so as part of the personal assistance service. Not allowing such support effectively excludes many people from CD services who are otherwise capable of directing their health care tasks as described in the NPA. It is a barrier to full participation in community life, achieving greater independence, and self-determination.” 

The Arc of Virginia appreciates the opportunity for all  stakeholders to offer comments for consideration on the Draft Manuals. 

GENERAL COMMENTS: 1. Purpose of Manual to provide explanation, clarification, definition, examples, possible service scenarios, and interpretation for providers to deliver consistent implementation of quality services, documentation and required reports across the Commonwealth. However, we have found that there are numerous items in the Manual that are more prescriptive than what is included within DD Waiver regulatory authority - which is problematic. The Manual should not be more prescriptive than regulations since the governing authority are the regs. The addition of regulatory citations would help as reference throughout the Manual as appropriate. 2. Consistency between Regulations and Manual is critical. There are multiple examples throughout the Manual of inconsistencies between licensing regulations, DD Waiver regulations and what’s required by DMAS in the Provider Agreement. All of this makes it confusing for the provider and creates additional administrative burden. It also complicates the rules for providers that provide “unlicensed services”. Because the service is unlicensed, it makes it difficult to know and fulfill requirements that refer to the licensing regulations and/or to forms referenced. 3. Chart with “Corresponding Regulations” and BI, FI and CL columns are a helpful visual and provide clarity regarding regulation reference at the beginning of each service. We recommend that a chart be used for all services in Chapter 4. (See page 78 as example). 4. There is an overall need to clearly delineate the responsibilities and requirements for support coordinator actions versus service provider actions. Ideally, support coordination would either have a companion Manual or minimally, within the Waiver manual, have clear sections within chapters and/or services. Possibly, even a separate chapter with ONLY the Support Coordination requirements and responsibilities. The lack of separation and specificity are confusing regarding responsibility and requirements of “providers” throughout the Manual. The question asked often throughout is “which provider is responsible”. 5. We request that overall instructions on how providers should round any fractions of service hours provided for billing purposes. This is not included in the current Manual but would be very helpful as an overall instruction to provide specification and consistency. In the past when we asked, we were told that these instructions were to be included in the future Manual in a chapter for “other services”. It would of course be efficient to include this information within the Waiver manual. CHAPTER 4: Table of Contents & Service Option Charts: Corrections Needed: • Individual & Family/Caregiver Training is incorrectly marked as included in the BI waiver - should be FIS Waiver • Workplace Assistance Services is incorrectly marked as only being included in the FIS Waiver - it is also included in the CL Waiver. Page 1 - Criteria to Be Eligible - Comment: What if they do not have "functional limitations in major life activities" - but might need Companion Care or Sensory Equipment (AT or DME)? Diagnostic Eligibility Page 2, paragraph 1: COMMENT: Correction Needed. Paragraph refers to “three of more criteria described in (1) through (5) above…” Please change bullets to numbers for clarity. Day Assessment Service Authorization Requests Page 22: Comment: Would prefer that the language used provide additional clarity than the 60-day assessment is an option (“may”) - but not required. Recommend - “Provider has the option to request a 60-day assessment prior to initiating plan for supports.” Page 23: Provider Discontinuation of Services. Comment: Regarding 10 business days advanced notice in writing. This is not always possible. Individual Supported Employment (ISE) services, for example, will end when an individual quits or is terminated from a position and DARS categories are open. Would prefer language that better reflects that this is best practice when possible but not required. Additionally, it indicates that in a situation in which health/safety concerns are the reason for discharge, DBHDS must be notified – who at DBHDS is to be notified? Assistive Technology (AT) General Comment: Assistive Technology (AT) is an HCBS waiver benefit that all recipients of DD waivers and CCC+ waivers are equally entitled to access in accordance with regulations at 12VAC30-122-270. Although there is only one regulation for AT, guidance for administration of it is inconsistent. AT requests for people with a DD waiver are approved by DBHDS according to the DD Waiver Manual Chapter IV and AT requests for people with the CCC+ waiver are approved by the MCO or KePRO according to the Durable Medical Equipment (DME) and Supplies Manual Chapter IV. Review of both manuals find extensive differences and variations, and both manuals are more restrictive than the AT regulations they are purported to clarify. These contradictions and inconsistencies represent the root causes of many of the barriers that individuals, providers, and DMAS are experiencing as reported by the HB2197 working group that DMAS was charged with hosting to identify barriers to accessing AT and related services as well as options for removing them. Making the administrative manual changes recommended below will remove many of these barriers that impact over 30,000 people with disabilities. Only the DD Waiver Manual is open for public comment; the DME Manual was closed in June 2021 after receiving zero comments. We strongly urge DMAS to revise both Manuals to appropriately reflect the AT regulations at 12VAC30-122-270. Suggested revisions for both manuals are provided below. Relevant Regs at 12VAC30-122-270. Page 49 - Service Description - 2nd to last sentence Comment: “Assistive technology devices are portable and authorized per calendar year” is inconsistent with the regulations, which do not require AT devices to be portable. Recommend DELETE “are portable and” to retain the calendar year portion of the sentence, which is consistent with the regulations. Page 50 - Examples - Allowable Equipment Table Comment: Lists allowable equipment and activities that may include a limited list that does not fully reflect the allowable scope of AT in the regs because it lists both types of AT and purposes of AT. Specifically, the allowable list in the manual does not reference AT that enables an individual to actively participate in other waiver services. This purpose of AT is referenced in both the regulations and in the manual on the previous page that lists what AT is supposed to enable. Recommend replacing the allowable equipment and services list on page 50 about the types of allowable AT to, “Allowable equipment and activities may include specialized medical equipment and ancillary equipment; durable or nondurable medical equipment and supplies; adaptive devices, appliances, and controls; and other equipment, devices, items, and software that meets the service definition.” Page 51 Comment: This is a stand-alone exclusion that is neither supported by the regs nor referenced in the allowable items section of the regs or the manual, “Items such as furniture shall not be approved if they are of general utility and are not of direct medical benefit.” The regulations require an independent professional consultation that should determine on its own merit if the AT is needed to, “enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, or to participate in other waiver services. (12VAC30-122-270),” in order for the AT to be approved, making this additional stipulation unnecessary. Recommend deletion of the entire sentence. Page 51 - Comment: Sentence about software compatibility is more restrictive than regulations, “AT providers must ensure that requests for software are compatible with the individual’s current computer.” This assumes all individuals have a computer at all, let alone one that is compatible with every type of software that might be evaluated as necessary AT by an independent professional’s recommendation. The regulations are clear that the independent professional shall determine the most appropriate item(s) for the individual’s needs, which may be compatible with a device that they already own or may require upgrades, enhancements, or a separate device. Recommend deletion of the entire sentence. Page 51 - Service Units and Service Limitations - 1st Bullet Comment: “for a specific timeframe” does not clarify the implementation of the regulation. The only timeframe specified in the regulations at (12VAC30-122-270) is the budget limit for a calendar year, and many prior authorization systems only accept a 1-month service period for the AT code used for service authorization requests. Recommend either deleting “for a specific timeframe” or revising to, “for the timeframe specified by the service authorization system.” Page 52 - Service Units and Service Limitations Bullet about AT Comment: under EPSDT for children is vague, confusing, and is more restrictive than the regulation. The regulation at (12VAC30-122-270) C.4. Service units and limitations says, “Requests for AT service via a DD Waiver shall be denied if the AT service is available under EPSDT.” Nowhere in any of the regulations are children under 21 limited to only AT available under EPSDT. Instead of instructions and guidance about how to coordinate the AT benefits that children are eligible to receive under both EPSDT and HCBS in order to comply with the regulation if the requested AT is not available to the child under EPSDT, the proposed manual language only says, “AT for individuals younger than 21 years of age must be accessed through the EPSDT benefit,” indicating children may only access AT under the EPSDT benefit. Recommend revision: “AT for individuals younger than 21 years of age may be requested via a DD Waiver if the AT is not available to the child under EPSDT.” Page 52 - Service Exclusions - 1st Bullet Comment: Assumes all of the items listed will only ever be for the purposes of convenience, restraint, or recreational or leisure purposes. This administrative declaration circumvents and undermines the fundamental requirement for an independent, professional consultation/evaluation, and could restrict individuals from accessing the least expensive, most cost-effective manner of meeting the regulatory purpose of AT, “to enable individuals to increase abilities to perform ADLs; to perceive control, or communicate with their environment; to actively participate in other waiver services; or are necessary for the proper functioning (12VAC30-122-270)” of other equipment. As drafted, the manual permits service authorization staff to overrule the independent professional if any item related to those excluded, regardless of compliance with the regulations. Blanket exclusions are unnecessary and contradictory to the several pages of criteria, guidance, exclusions, and instructions in the manual that safeguard the AT fund for appropriate and compliant utilization. Recommend deletion of the entire first bullet. Page 53 - Last Bullet - Service Exclusions Comment: Same as regulation. Additional explanation or guidance would be appreciative. It is about duplication of payment for services that are reasonable accommodation requirements of the ADA and other Acts. What constitutes a duplication of payment? If an AT service is otherwise paid by whom? The HCBS AT budget? The Waiver? A Waiver provider? The State Plan? Another State entity? If the individual already has the AT that provides reasonable accommodation, then the independent professional would not recommend it as a needed item. Please describe a real-world example of a duplicate waiver payment for AT that supports this restriction. Recommend revision with example that provides a better understanding of the regulation. Page. 54 - Provider Documentation Requirements Comment: states “Documentation in the Support Coordination record of notification by the individual or individual’s representative family/caregiver of satisfactory completion or receipt of the service or item.” This is supported in the regulations but is not a requirement that the AT provider can fulfill. Recommend removing this bullet from the Provider Documentation Requirements and consider adding a separate Support Coordinator Requirements list and/or adding it to the Support Coordination Manual also currently open for public comment. Page 54 Provider Documentation Requirements - Last Bullet - Comment: States for the “Support Coordinator to perform and document a face-to-face visit to assure that the individual can use the AT safely and appropriately.” Overly burdensome. This is not a requirement for provider documentation and is not supported in the regulations at (12VAC30-122-270). The other documentation requirements listed in the manual are copied from the regulations without additional detail or guidance, but this particular bullet does not reflect any requirement in the regulations for a face-to-face visit or assurance of safe and appropriate use. Only a professional trained in the AT item could make an assurance that the individual can use the AT safely and appropriately, which is part of the required independent professional consultation/evaluation. Recommend deletion of the entire sentence. Community Guide Services Page 59 - 3rs Bullet - Documentation Requirements Comment: States “Observations of the individual’s responses to the service must be available in at least a daily note”. Community Guide services are not necessarily provided on a daily basis. Is this needed and realistic. Recommend deleting “daily” from note. Electronic Home-Based Supports (EHBS) General Comment: The regs and the manual are aligned with one another in a way that only makes sense for equipment. In order for providers to deliver services under EHBS, the unit of service cannot be limited to only one. Recommend Additional Language Be Added: "Only one unit of service is only appropriate for equipment or items that are delivered once. Services that include ongoing monitoring and other supports delivered electronically occur periodically and routinely as needed by the individual, similar to therapeutic consultation. Please consider separating administration of EHBS coverage of equipment from EHBS coverage of services to allow for appropriate and compliant service authorization and billing for ongoing services." Page 63 - Service Documentation Requirements - Bullet #2 Comment: This documentation is the requirement of the Support Coordinator and not the EHBS provider. Individual and Family Caregiver Training Page 70: Indicates that contact notes, monthly notes, and quarterly reports must be completed. This is more than the regulations require. Is also duplicative. It is also more information than is required for other services. Other services require a quarterly review. Clarification is needed if monthly summaries are needed when there is a quarterly review being completed. Transition Services Page 74 Paragraph 1 and Page 75 Last Paragraph - Inconsistent language Comment: Page 74 includes language that an “individual has 30 days after transitioning to apply for Transition Services”. Page 75 states that “service authorization must be obtained within 30 days of discharge. Recommend clarification and consistent language be used to avoid confusion. Benefits Planning Page 90: Criteria/Allowable Activities 1st Paragraph Comment: DELETE “or” before “employment status” and ADD “or need for work incentives”. Page 94: Paragraph 1: Indicates that this service requires face to face contact. Comment: Regulations do not specify that this be a face-to-face contact. Alternative options must be available including telehealth and virtual options. Overly prescriptive and not included in regulations. Page 95: Mid-page - Bullet 1 - Comment: ADD “or is not available” after “have been explored and exhausted”. Also, please clarify what documentation is needed to fulfill the requirement of “explored or exhausted”. Page 95: Mid-page - Bullet 2 - Indicates there should be documentation of “All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS” Comment: Should also include “DSS and SSA as appropriate” for this particular service. Community Engagement Page 102 - Criteria/Allowable Activities Paragraph 1 - Last Sentence Comment: Underlined sentence is confusing. Should “community engagement” be substituted for “supported employment”? Page 104 - 7th Bullet: Comment: ADD “independent” before “living skills” Group Day Services Page 112 - Service Definition/Description 1st Paragraph - Last Sentence: DELETE “these services”. Page 114: Semi-Predictable Events Paragraph 1: States “The provider may request between 3-5 hours of additional “community engagement” per week that will allow the individual to choose additional community outings. Comment: Shouldn’t this read: “The provider may request between 3-5 hours of additional “group day” services per week that will allow the individual to choose additional “group day” activities. It is not clear. If Community Engagement - then it should be included in the Community Engagement service section,

Supported Employment Services Page 119: Criteria/Allowable Activities Comment: • Recommend that bullets be entirely realigned AND be delineated between Individual SE and Group SE. • The first sentence indicates that there is one element that is limited to ISE only. However, there are seven elements listed and are provided in GSE services. The “this element is limited…” should be at the end of the previous bullet. It should state - “Individual job development, with or without the individual present that produces an appropriate job match for the individual and the employer to include job analysis or determining job tasks, or both. This element is limited to ISE only and is not permitted for GSE” • Allowable activities should allow for reimbursement for collateral contacts, including Workplace Assistance if the service is provided. • Staff provision of transportation – need criteria for what is considered “unavailable or inaccessible” and how this is to be documented. • States - “For DMAS reimbursement to occur, the individual must be present, unless otherwise noted, when these activities occur: Vocational or job-related discovery or assessment, Supports to ensure the individual's health and safety during the hours of work” Comment: We recommend that the above allowable activities be noted that these activities can be conducted without the individual being present. In fact, many discovery and assessment documents are reviewed in the absence of the individual. Furthermore, the coordination and logistics of arranging health and safety supports, such as coordination with the employment site or family members, would precede the implementation and therefore occur without the individual being present. Page 120: Customized Employment Comment: There is nothing indicated in the manual regarding who may provide this service. Under DARS funded CE only ACRE Customized Employment certified specialists may provide this service – is this the expectation for DBHDS or can any ISE employment specialist provide it? Page 120 - Job Search Planning Comment: the following “conduct an analysis of benefits which may be accessed through Benefits Planning” is unclear. Benefits planning is a separate service. What is the “analysis of benefits” that is being referred to? While most employment specialists can identify when an individual would need that service, it is the role of the support coordinator to refer for the service and coordinate services. Page 122: Documentation of the Individual’s Ineligibility for SE Services 5th Bullet: States “Documentation of the individual’s ineligibility for supported employment service through DARS or IDEA, as applicable. If the individual is ineligible to receive service through IDEA, documentation is required only for lack of DARS funding. Acceptable documentation for the lack of DARS or IDEA funding would include a letter from either DARS or the local school system or a record of a telephone call, including name, date, and person contacted, documented either in the individual's file maintained by the support coordinator, on the ISP, or on the supported employment provider's supporting documentation. Unless the individual's circumstances change, for example, the individual is seeking a new job, the original verification may be forwarded into the current record or repeated on the supporting documentation on an annual basis” Comment: We recommend that the responsibility for documenting Waiver ineligibility based on DARS or IDEA eligibility should be the responsibility of the Support Coordinator and should be indicated as a Support Coordinator responsibility instead of a provider responsibility. Workplace Assistance Page 124: Criteria/Allowable Activities Comment: ADD “This service is designed to support individuals in competitive, integrated positions for whom all options for independence in regards to appropriate job match, reasonable accommodations, and the utilization of natural supports in the workplace have been explored, exhausted and documented. This service is supplementary to individual supported employment in order to maintain stability in the workplace.” Page 124 - Paragraph 1 Comment: Includes a typo. Should read “has learned the basic skills…” Additionally, there should be information under criteria indicating that natural supports and accommodations are not available for the identified support needs. Skilled Nursing Services Overall Comment - Page 140 - 2nd to last bullet - There is a significant change in the Manual which is in conflict with the DD Waiver regulations regarding the period for which an authorization is completed. The change is more prescriptive than the regulations and changes the 1-year authorization in line with an individual’s ISP year to a 6-month authorization. The Manual should not be more prescriptive than the regulations. This places additional burden on providers. A change in this policy needs to go through the regulatory process or legislative process for full vetting. Group Home Residential Page 150 - Service Limitations Comment: Regulation 12VAC30-122-390 says “March 31, 2021” and the Manual says “May 1, 2021” Consistency is needed between regulations and Manual. Page 153 - 1st Paragraph - Last Sentence Comment: Manual states “Each quarterly review will represent the quarterly data. However, the fourth quarter will provide an annual summary in addition to the fourth quarter data. This is not authorized in regulations. Inconsistent. Sponsored Residential Page 175 - Last Bullet Comment: DELETE last sentence “Four written reviews span the entire ISP year.” Language is not consistent with other residential services. Consumer Directed Services & Services Facilitation Page 203 Comment: After the description of CD services in general, and before the beginning of what is currently on Page 204, we recommend that you add the following regulatory language in the Manual for clarification and consistency - 12VAC30-122-150, A, 2, d, e, and f Page 204 - Bullet 1 -- Comment: Recommend clarification around whether or not the EOR must live with the individual receiving services. Providers often get “pended” for this. Page 204 - Last paragraph - After the first sentence, ADD “If the individual chooses not to have service facilitation, the support coordinator must document which family member or caregiver other than the EOR shall perform all of the duties and meet all of the requirements of a CD services facilitator.” (VAC1230-122-150, A, 2, e) Page 205 - Paragraph 3 - “When two individuals who live in the same home….”. Recommend ADD “If the individual has chosen not to have Services Facilitation, then the family member or caregiver acting in that capacity will be responsible this assessment.” Page 205 - Paragraph 4 - Recommend the first sentence to say “An individual who has chosen consumer direction may choose, at any time, to voluntarily change all or part of their services to the agency-directed model as long as he/she/they continues to qualify for the specific services.” Comment: For example, he/she/they may choose to move just Respite or part of the Personal Care hours to agency, while maintaining all, or a portion of their Personal Care under the consumer-directed model of service.” Recommend the second sentence in that paragraph to read, “The services facilitator, or family member or caregiver acting in that capacity, and the support coordinator are responsible for assisting….” Page 205 - Last bullet - If the change recommended above for Rec 1is adopted - this bullet can remain as is. Page 207 - Paragraph 1 - This is the explanation that needs to be moved up or copied in the CD section above SF. See recommendation #1. Page 207 - Paragraph 3 - The second to last sentence in this part is not proper grammar. Recommend - “Transitions from the CCC Plus Waiver to a DD waiver will only occur only on the first day of a month.” Also, the last sentence should read, “The SF, or family member or caregiver acting in that capacity, has a role to play in this process in order to ensure continuity of care.” Page 207 - Last Section Bullet 2 - there needs to be a space between the words "should" and "call" in the last sentence. Page 208 - Bullet 5 - Recommend to read “For consumer-directed services, the services facilitator, or family member or caregiver acting in that capacity, must submit the Fiscal Agent Request Form to the FE/A and initiate the change in discal employer agent, if applicable, and the change from CCC Plus Waiver services to DD Waiver services.” Page 209 - Last Bullet - Language is different from regulations - needs consistency and not more prescriptive language. The regs (12VAC30-122-500, B, 4) state “The services facilitator, during routine quarterly visits, shall also review and verify….” The manual states “routine semi-annual visits”. This language should be changed to match the regs. The manual should also add “or family member or caregiver acting in that capacity” to that sentence as well. Page 210 - Bullet 1 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must be available during standard business hours to the individual or EOR by telephone.” Page 210 - Bullet 2 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, will assist the individual or EOR….” Page 210 - Bullet 3 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must complete the assessments, ….” Page 210 - Bullet 4 - Language inconsistent with regulations. The regs (12VAC30-122-500, B, 8) state “Service facilitation service shall be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but at a minimum quarterly routine visits shall take place.” The manual has been changed to say, “Services facilitation will be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but, at a minimum, routine semi-annual visits.” The manual should be changed to match the regs. Also, the language “or family member or caregiver acting in that capacity” needs to be added. Page 210 - Last Sentence - Recommend language change to “The SF, or family member or caregiver acting in that capacity, may not be the individual enrolled….” Page 211 - 1st Sentence - Recommend language change to “The SF, or family member or caregiver acting in that capacity, must document….” Page 211 - 2nd Sentence - Recommend language change to “Should a CD employee not report for work or terminate employment without notice, the SF or family member or caregiver acting in that capacity, upon the individual’s or EOR’s request….” Page 211 - Service Documentation & Requirements - • 1st Sentence - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must maintain….” • Bullet 1 - Recommend language change to “his” to “his/her/they” in sentence, “….receipt of training on his responsibility for the accuracy….” • Bullet 2 - Typo - "hat" should be "that" • Bullet 3 - What is considered a “contact”? This needs clarification. Also, what is considered “medical record Page 212 - Bullet 2 - Comment: Language in the Manual should match the regulations. The Manual Language is more prescriptive. The manual reads, “In a situation whereby the individual’s needs have changed significantly, the plan for supports must be reviewed by the provider.” The regs (12VAC30-122-500, E, 3, g) state “Documentation indicating that desired outcomes and support activities of the plan for supports have been reviewed by the consumer-directed services facilitator provider quarterly, annually, and more often as needed.” Manual pg 212, bullet 2, the sub-bullets ? These sub-bullets do not exist in the regs. Why are we being made to document MORE than what is in the regs??? Isn’t that considered more restrictive than the regs? Page 212 - Bullet 3 - It is missing the number of calendar days in the language. Also, there is no time limit in the regs, so any introduction of a time limit on when the review must be submitted to the Support Coordinator is more restrictive than the regs. Page 212 - Bullet 3 - Sub-Bullet 1 - There is no sub-bullet in the regulations. This needs to be a dark bullet and moved to the left to align with the other bullets.

Quality Management and Utilization Reviews Introduction Page 1: • First paragraph, 2nd sentence - who is DMAS’s “designated agent”? Recommend clarification between DMAS QMR staff and any subcontracted contractor for financial audits, etc. • First paragraph, 4th sentence states “DMAS conducts compliance reviews on providers that are found to provide services in excess of established norms, ..." Comment: Shouldn't this be just on those that do not provide services in accordance with the regulations? What does "established norms" mean? Language needs to be changed or definition of “established norms” needs to be provided. General Requirements Page 1: • Second paragraph, 1st sentence states "DMAS participation standards and policies". Comment: Shouldn’t this refer to regulations as in the following sentence? If “standards and policies” is retained - definition or citation needs to be included. Page 2: • 1st sentence - general grammar problem - comma needed following the word "individuals”. • Second paragraph, 1st sentence - Who is "staff"? We assume “DMAS QMR staff” in this instance. Comment: Helpful to state and delineate between DMAS QMR staff and provider staff within this paragraph and others to provide clarity. Also, "staff may request licenses” - However, not all providers are required to have staff that is licensed. Add “providers and staff required to have licenses”. Differentiate between requirements of services that are licensed and services that are not licensed regarding criminal background checks and what “documentation” is required. • Third paragraph, 2nd sentence - Again, the requirement to be in compliance with "DMAS provider agreements and policies" Comment: Shouldn’t this refer to regulations? If “standards and policies” is retained - definition or citation needs to be included for clarity. • Fourth paragraph, 3rd sentence - Use of the word "provider" here. Comment: Assume this means the Agency Provider and not the Personal Care provider. However, “provider” is used interchangeably for both throughout document. “Staff” is also used interchangeably throughout the document. Clarity and specificity is needed consistently. Page 3: • Bullet 1, 1st sentence - states "within the program's guidelines"? Should this be "in accordance with regulations"? • Bullet 1, 2nd sentence - Same comment as above related to the use of the word "provider". • Bullet 1, 3rd sentence - Comment: What is considered to be "the individual's record"? Add specific reference to what record. Is it enough to document these things in a provider’s system? Also, what is classified as "any substantial change"? And what specific "documentation of such change" is required? Please add specificity. • Bullet 1, 4th sentence - Recognize that provider’s responsibility to identify “substantial changes” and inform the Support Coordinator. Comment: However, it is the Support Coordinator’s role to obtain and coordinate those services that the individual requires to remain in the community and not the provider. The "or" that follows that requirement should be replaced with "so that the Support Coordinator can obtain any other services,...." • Bullet 3, 2nd sentence - Clarity needed. Comment: Who is considered "provider staff"? and who is the "provider agency representative"? In the case of Service Facilitation - clarity is needed since the SF is the one both in communication with the individual AND the one responsible for the oversight of the plan. • Manual Pg 3, bullet 3, last sentence ? where should the "providers" find the remaining list of quality of supports if this is just "some" of them? Remember, not every provider is licensed, so we are only following the regulations and this handbook. • Manual Pg 3, bullet 4 ? are we allowed to use electronic signature now? Where did that change in the regulations? Page 4: • Bullet 1 - Use of "provider" again and "maintain a record"? Comment: Can that be just be in the provider’s system? It's confusing since the next sentence mentions the forms. So is the "record" the "form"? Are those one and the same? Why not use the same word for both spots? • 1st full paragraph - "DMAS will review the provider's performance in all the outcome areas to determine the provider's ability to achieve high quality supports..." Comment: This is where that word "provider" gets used interchangeably again. The SF writes outcomes based on the Part 3, but the outcomes are for the Personal Care Attendant to provide to the individual and not for the SF to provide to the individual. So, who is the "provider" whose performance DMAS is reviewing? Further clarification is needed. • General Comment on consistency - The language is now referring to DMAS. "DMAS will review", "DMAS will evaluate", "DMAS may require". Before, in this same document, it refers to "staff". Consistency is needed throughout. • 2nd full paragraph - Shouldn’t the regulations be mentioned here instead of “policies and procedures”? • Bullet 1 - Further clarity is needed. What exactly is meant by "periodically"? • Bullet 5, sentence 1 - A sentence is needed to differentiate Service Facilitation and CD services from other services and their specific requirements. States "Staff" will meet with at least one individual or PCG to determine satisfaction with the provider. Which provider is that? The SF provider agency? Or the PCA provider? Not clear regarding what would be measured for SF. Page 5: • Bullet 1 - why is "provider" underlined? Who is "staff"? Appreciate the reference to regulations vs “policies and procedures”. • Bullet 3 - Who is submitting this letter to these other agencies? Specificity needed. Comprehensive and Ongoing Assessment and Planning Page 8: Bullet 1, sub-bullet 5 - A parenthesis is missing here. Page 10: Bullet 3 - Why is "the waiver enrollment date" underlined? Services are Delivered, Reviewed and Modified as Needed Page 11: Comment: Is this for all providers or specific to Case Management? The first bullet/sub-bullet seems to speak to each service provider, but then the second sub-bullet is specific to Case Management. Then the third sub-bullet goes back to "each service provider". Recommend to separate and list bullets under either provider and case management for clarity Page 12: Main Bullet Comment: Sub-bullet 1 - Provide specificity in Manual. What DMAS form is to be used for the quarterly review? There is currently no consistency from CSB to CSB on what documentation is required to be used for quarterlies. There is also no consistency as to what has to be in that quarterly review. Specificity would be helpful to provide consistency. Page 13: • 1st sub-bullet ? "All providers must be invited to the meeting and participate in the development of the new ISP annually." Are SF required to be present at the meeting? Service Facilitators are not compensated for this meeting and can only bill for a reassessment visit. These meetings can be up to 3+ hours. Services Delivered are Consistent With Service Limits Page 13: Bullet 1, sub-bullet 2 - Comment: Need additional specificity for Service Facilitation - recommend separate sub-bullet. "The number of hours does require authorization." What hours? MT Units? PCA hours? Respite Hours? Companion Hours? The hours the SF is working? Page 15: Bullet 2 Comment: Paper timesheets went away a long time ago, so the EOR and employee will not be signing them. Time is either logged via app, online portal, or by calling in using IVR. So billing for CD services will not be supported by a timesheet that is signed. This point in the manual needs to be removed. Support Coordinator/Case Manager/Provider Responsibilities Page 23: Comment: Need to REMOVE “Provider” from this section. “Provider” should not be included in this title when the first paragraph says that the following things are the responsibility of the support coordinator/case manager, and doesn't mention the provider? None of the things listed are the responsibility of the provider.

DD Waivers Manual, Chapter IV, Therapeutic Consultation (TC), pg. 142

Regulations at: 12VAC30-122-550. Therapeutic consultation service.

• People with a BI waiver need access to therapeutic consultation, “professional consultation to assist individuals, parents, guardians, family members, and any other providers of support services with implementing the ISP.” This service provides expert consultation to the entire support system that enables them to achieve outcomes in the ISP without the expense of ongoing therapy services.
  • DMAS is aware of significant and systemic barriers to accessing technology that individuals need to interact with their providers and greater community. TC providers are specifically and uniquely qualified to provide assistive technology and medical equipment assessments, recommendations, training, and follow-up adaptations in accordance with the manual and the regulations, “provides assessments, development of a therapeutic consultation support plan, and teaching in any of these designated specialty areas to assist family members, caregivers, and other providers in supporting the individual.” Increasing access to TC to more people for AT assessment and facilitation would alleviate these barriers for individuals who don’t know how to engage and participate in the virtual environment, including telemedicine with healthcare providers.
  • TC offers an opportunity for provider choice from multiple disciplines and is one of the few regulated and reimbursable services that can be delivered effectively from a safe distance via telehealth and telephonic consultation. Individuals and families want more control over the services they receive and how they receive them. Access to consultation with an expert in any discipline of therapy would demonstrate to advocates Virginia’s commitment to the principles of the DOJ settlement, which includes all HCBS waiver recipients.
  • All individuals, regardless of which waiver they have, is experiencing the detrimental impacts of uncontrollable environmental changes throughout our community, including support provider shortages, limited choice and control of care setting and service duration, and lack of workforce modernization resources for service providers. Individuals with a BI waiver are experiencing equally disruptive changes to the capabilities of their support system to implement their ISP as those with the FIS and CL waivers.

• Pg. 142, “consultation provided by members of … disciplines that are designed to assist… with implementing the ISP,” mirrors the regulation at 12VAC30-122-550. However, because assistive technology professionals (ATPs) are not listed in the examples of disciplines that can provide TC, DMAS will not enroll them as providers. This is a wasted opportunity. The Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) provides standardized credentialing for an ATP Certification, “The ATP certification recognizes demonstrated competence in analysing the needs of consumers with disabilities, assisting in the selection of appropriate assistive technology for the consumers' needs, and providing training in the use of the selected devices.” The TC manual and regulation provide allowable activities examples that include, “Assessing the individual's need for an assistive device for a modification or adjustment of an assistive device, or both, in the environment or service, including reviewing documentation and evaluating the efficacy of assistive devices and interventions identified in the therapeutic consultation plan.” The ATP discipline meets the regulatory requirement as a discipline, “designed to assist with implementing the ISP 12VAC30-122-550.”
  • Suggest adding “Assistive Technology Professional” to the list of example disciplines appropriate to provide TC services.

Chapter 2, Page 5, Fingerprinting
Include the exemption for fingerprinting of services facilitators as the Code of Virginia does not include a provision allowing for these employee background checks to include finger printing.
Include the exemption for fingerprinting of consumer-directed staff. The fiscal agent nor the employer of record obtain this level of back ground check.

Chapter 2, Page 5, CD Employee Responsibility to Notify of Convictions
Clarify what the Employer of Record is to do if an employee reports a conviction.

Chapter 2, Page 31, Sleeping or Living Units
Provide a definition of a living unit including how this is different from the sleeping unit.

Chapter 2, Page 32, Accessibility
Include in the examples of required accessibility, all features of the kitchen and outdoor areas used by the individual.

Chapter 2, Page 36, Support Coordination for People with DD Other Than ID
Clarify that the “provider” is the CSB or BHA, not the contractor. Not all of the requirements listed can be achieved by the contractor due to CSB and BHA structures and DBHDS licensing requirements.

Chapter 2, Page 50, Transition Services
Can these services be provided by any Medicaid targeted case management provider or only DD and ID case management?

Chapter IV, Page 6, Patient Pay Consumer-Directed Services
Include the process to notify the individual and employer of record about patient pay.

Chapter IV, Page 9, Removal from Waiting List
Regarding the last sentence of the first paragraph, what must the CSB do with the provided Choice forms?

Chapter IV, Page 13, CL Waiver Requirement for Group Home or Sponsored Residential
This description of CL Waiver assignment is unclear. Is the individual expected to use group home or sponsored residential within a certain timeframe in order to be assigned a CL Waiver?

Chapter IV, Page 40, Likely to Have an ID Diagnosis
The assumption that people have ID has been problematic for people with DD for many years. Using this likely assumption in the Manual is inappropriate. Most people with DD do not have an ID diagnosis. In the past, an ID diagnosis was sought by some parents and providers due to funding levels for case management, previous requirements to have an ID diagnosis for some waiver services, and other antiquated perceptions about abilities and services.

Chapter IV, Page 40, Spina Bifida
Correct the spelling of spina bifida in the fourth paragraph.

Chapter IV, Page 52, AT Service Exclusions
The exclusions listed in the last paragraph are concerning. These, and similar items, often have significant therapeutic value depending on the needs and preferences of the person with a disability.

Chapter IV, Page 66, EM Exclusions
Multiple wheelchair ramps in the same residence may be necessary to ensure a safe exit from the home. For example, one entrance may be blocked by a fallen tree during a storm or unusable due to snow.

Previous modifications to the same room should be allowed. People use Waiver services for years – entire lifetimes. It is unrealistic to expect a previous modification to remain useable or appropriate for the individual for a lifetime. Previous modifications to the same room should be allowed.

Chapter IV, Page 76, Locks
Clarify that locks must be on livable areas such as bathrooms and bedrooms.

Chapter IV, Page 93, Benefits Planning Service Limitations
Individuals have the right to choose their employment network (EN) provider. Granted most people choose DARS. However, for individuals who choose a different EN, it does not matter if the benefits planning is available through DARS.

Chapter IV, Page 111, Employment and Community Transportation Requirements
Clarify that the provider does not attend the annual plan meetings. The rate of reimbursement for this service does not include plan meetings.

Chapter IV, Page 133, Private Duty Nursing
Private duty nursing providers often refuse to provide personal care services. Personal care attendants may not make medical judgements or be involved with vents, trachs and other sterile techniques, even with nurse delegation (as explained further in this Manual). This limits personal care to a period of time when the nurse is not present if something were to become dislodged with the ventilator or other device that requires the use of a sterile technique.

Chapter IV, Page 182, Companion Services Criteria
The fifth paragraph appears to be an incomplete sentence. Is the intent to state that companion services are limited to no more than eight hours in a 24-hour period?

Chapter IV, Page 195, Consumer-Directed Documentation by the Personal Assistant
There is no requirement for the documentation in the second and third bullets. While some employers of record may want to require this documentation, there is no program requirement for this.

Chapter IV, Page 200, CD Employees Working 16 Hours or More
In the first paragraph, clarify if this is a limitation based on employer of record or a limitation of the assistant, regardless of how many employers they work for.

Chapter IV, Page 204, Using CD Without Services Facilitation
The Manual should include guidance on how this is to be done.

Chapter IV, Page 204, Selection of EOR
Include the use of the DMAS-95. This was previously done by the services facilitator, but will now need to be done by the case manager since the case manager now decides if the EOR is appropriate.

Chapter IV, Page 209, CD Monitoring
Clarify that the phone contact to conduct the monitoring to prepare the quarterly report is a billable service
Clarify whether a quarterly monitoring is required for companion services or if it remains a semi-annual monitoring timeframe.

Chapter VI, Quality Management and Utilization Reviews, Page 6, VIDES timeline
Clarify what timeline DMAS expects for the “annual” VIDES. Is it within 365 days of the last review, a specific timeframe before the annual Waiver plan development, or other timeline?

Chapter VI, Quality Management and Utilization Reviews, Page 7, Evaluations
The language used, “psychological or other evaluation” is good. Too often people with DD have unnecessarily gone through psychological evaluations when their DD diagnosis is better determined, or already appropriately determined, by other evaluations.

Chapter VI, Quality Management and Utilization Reviews, Page 8, Plan for Supports, Case Management
As is written in the fifth clear bullet, it appears that Case Management is a waiver service. Clarify that case management is a state plan service.

Chapter VI, Quality Management and Utilization Reviews, Medical Evaluation, Page 9
The assumption that all people with DD need an annual physical is not is not a Medicaid requirement. The Manual correctly states that a medical examination should occur whenever needed. Further clarification should be included in the Manual to guide a better understanding of this matter and minimize unneeded medical examinations.

Chapter VI, Quality Management and Utilization Reviews, Page 11, Plan of Support
Clarify the development of plans of support (Part V) for consumer-directed services. The provider is responsible for working with the team to develop the plan. In the case of consumer-directed supports, the provider is the direct staff (attendant, companion or respite provider). They currently do not develop plans of support and should not. This exception should be included in the Manual.
For individuals who choose to use consumer-directed supports without services facilitation, if the final decision is to require the development of plans of support for consumer-directed services, this will be the responsibility of the case manager and should described in the Manual.

Chapter VI, Quality Management and Utilization Reviews, Page 11, Service Documentation
In reference to the last bullet on page 11, clarify that this documentation does not exist for consumer-directed services. This bullet requires the case manager to look at documentation that is not available to them.

Chapter VI, Quality Management and Utilization Reviews, Page 17, Patient Pay with Consumer-Directed Services
The Manual should include a description of how the assignment of patient pay occurs for consumer-directed services, including notification to the employer of record and the individual, if different.

Chapter VI, Quality Management and Utilization Reviews
The Manual should include details about case management responsibilities and documentation requirements when an individual who uses consumer-directed services elects not to use services facilitation.

Appendix B, EPSDT, Page 5, Assistive Technology
In the second paragraph of this section:
An IEP is an individualized education program, not a plan.
Assistive technology required by an IEP is an allowable school-related Medicaid funded service. See the EPSDT Manual, Appendix A, page 5.

Appendix B, EPSDT, Page 6, Nursing Services
Add clarification that the individual must be receiving one of the DD Waivers services in order to continue eligibility for their Waiver. If a child develops the need for nursing services subsequent to receiving and using the Waiver, they must continue to use a Waiver service to maintain their Waiver.

DD Waiver Manual - Chapter 4 - Part 1 of 2
30-Day Public Comment - vaACCSES

GENERAL COMMENTS:

1. Purpose of Manual to provide explanation, clarification, definition, examples, possible service scenarios, and interpretation for providers to deliver consistent implementation of quality services, documentation and required reports across the Commonwealth. However, we have found that there are numerous items in the Manual that are more prescriptive than what is included within DD Waiver regulatory authority - which is problematic. The Manual should not be more prescriptive than regulations since the governing authority are the regs. The addition of regulatory citations would help as reference throughout the Manual as appropriate. 
2. Consistency between Regulations and Manual is critical.  There are multiple examples throughout the Manual of inconsistencies between licensing regulations, DD Waiver regulations and what’s required by DMAS in the Provider Agreement.  All of this makes it confusing for the provider and creates additional administrative burden.  It also complicates the rules for providers that provide “unlicensed services”.  Because the service is unlicensed, it makes it difficult to know and fulfill requirements that refer to the licensing regulations and/or to forms referenced.
3. Chart with “Corresponding Regulations” and BI, FI and CL columns are a helpful visual and provide clarity regarding regulation reference at the beginning of each service.  We recommend that a chart be used for all services in Chapter 4. (See page 78 as example).
4. There is an overall need to clearly delineate the responsibilities and requirements for support coordinator actions versus service provider actions.  Ideally, support coordination would either have a companion Manual or minimally, within the Waiver manual, have clear sections within chapters and/or services. Possibly, even a separate chapter with ONLY the Support Coordination requirements and responsibilities. The lack of separation and specificity are confusing regarding responsibility and requirements of “providers” throughout the Manual.  The question asked often throughout is “which provider is responsible”.
5. We request that overall instructions on how providers should round any fractions of service hours provided for billing purposes. This is not included in the current Manual but would be very helpful as an overall instruction to provide specification and consistency. In the past when we asked, we were told that these instructions were to be included in the future Manual in a chapter for “other services”.  It would of course be efficient to include this information within the Waiver manual.

CHAPTER 4:

Table of Contents & Service Option Charts:
Corrections Needed:

• Individual & Family/Caregiver Training is incorrectly marked as included in the BI waiver - should be FIS Waiver
• Workplace Assistance Services is incorrectly marked as only being included in the FIS Waiver - it is also included in the CL Waiver.

Page 1 - Criteria to Be Eligible -
Comment:  What if they do not have "functional limitations in major life activities" - but might need Companion Care or Sensory Equipment (AT or DME)?

Diagnostic Eligibility

Page 2, paragraph 1:
COMMENT:  Correction Needed. Paragraph refers to “three of more criteria described in (1) through (5) above…”  Please change bullets to numbers for clarity.

Day Assessment Service Authorization Requests

Page 22:

Comment:  Would prefer that the language used provide additional clarity than the 60-day assessment is an option (“may”) - but not required. Recommend - “Provider has the option to request a 60-day assessment prior to initiating plan for supports.”

Page 23:  Provider Discontinuation of Services.

Comment: Regarding 10 business days advanced notice in writing. This is not always possible. Individual Supported Employment (ISE) services, for example, will end when an individual quits or is terminated from a position and DARS categories are open. Would prefer language that better reflects that this is best practice when possible but not required. Additionally, it indicates that in a situation in which health/safety concerns are the reason for discharge, DBHDS must be notified – who at DBHDS is to be notified?

Assistive Technology (AT)  

General Comment: Assistive Technology (AT) is an HCBS waiver benefit that all recipients of DD waivers and CCC+ waivers are equally entitled to access in accordance with regulations at 12VAC30-122-270. Although there is only one regulation for AT, guidance for administration of it is inconsistent. AT requests for people with a DD waiver are approved by DBHDS according to the DD Waiver Manual Chapter IV and AT requests for people with the CCC+ waiver are approved by the MCO or KePRO according to the Durable Medical Equipment (DME) and Supplies Manual Chapter IV. Review of both manuals find extensive differences and variations, and both manuals are more restrictive than the AT regulations they are purported to clarify.

These contradictions and inconsistencies represent the root causes of many of the barriers that individuals, providers, and DMAS are experiencing as reported by the HB2197 working group that DMAS was charged with hosting to identify barriers to accessing AT and related services as well as options for removing them. Making the administrative manual changes recommended below will remove many of these barriers that impact over 30,000 people with disabilities. Only the DD Waiver Manual is open for public comment; the DME Manual was closed in June 2021 after receiving zero comments. We strongly urge DMAS to revise both Manuals to appropriately reflect the AT regulations at 12VAC30-122-270. Suggested revisions for both manuals are provided below.

Relevant Regs at 12VAC30-122-270.

Page 49 - Service Description - 2^nd to last sentence
Comment:  “Assistive technology devices are portable and authorized per calendar year” is inconsistent with the regulations, which do not require AT devices to be portable. Recommend DELETE “are portable and” to retain the calendar year portion of the sentence, which is consistent with the regulations.

Page 50 - Examples - Allowable Equipment Table

Comment:  Lists allowable equipment and activities that may include a limited list that does not fully reflect the allowable scope of AT in the regs because it lists both types of AT and purposes of AT. Specifically, the allowable list in the manual does not reference AT that enables an individual to actively participate in other waiver services. This purpose of AT is referenced in both the regulations and in the manual on the previous page that lists what AT is supposed to enable.

Recommend replacing the allowable equipment and services list on page 50 about the types of allowable AT to, “Allowable equipment and activities may include specialized medical equipment and ancillary equipment; durable or nondurable medical equipment and supplies; adaptive devices, appliances, and controls; and other equipment, devices, items, and software that meets the service definition.”

Page 51

Comment: This is a stand-alone exclusion that is neither supported by the regs nor referenced in the allowable items section of the regs or the manual, “Items such as furniture shall not be approved if they are of general utility and are not of direct medical benefit.” The regulations require an independent professional consultation that should determine on its own merit if the AT is needed to, “enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, or to participate in other waiver services. (12VAC30-122-270),” in order for the AT to be approved, making this additional stipulation unnecessary.

Recommend deletion of the entire sentence.

Page 51 -
Comment:  Sentence about software compatibility is more restrictive than regulations, “AT providers must ensure that requests for software are compatible with the individual’s current computer.” This assumes all individuals have a computer at all, let alone one that is compatible with every type of software that might be evaluated as necessary AT by an independent professional’s recommendation. The regulations are clear that the independent professional shall determine the most appropriate item(s) for the individual’s needs, which may be compatible with a device that they already own or may require upgrades, enhancements, or a separate device.

Recommend deletion of the entire sentence.

Page 51 - Service Units and Service Limitations - 1^st Bullet
Comment: “for a specific timeframe” does not clarify the implementation of the regulation. The only timeframe specified in the regulations at (12VAC30-122-270) is the budget limit for a calendar year, and many prior authorization systems only accept a 1-month service period for the AT code used for service authorization requests.

Recommend either deleting “for a specific timeframe” or revising to, “for the timeframe specified by the service authorization system.”

Page 52 - Service Units and Service Limitations Bullet about AT

Comment: under EPSDT for children is vague, confusing, and is more restrictive than the regulation. The regulation at (12VAC30-122-270) C.4. Service units and limitations says, “Requests for AT service via a DD Waiver shall be denied if the AT service is available under EPSDT.” Nowhere in any of the regulations are children under 21 limited to only AT available under EPSDT. Instead of instructions and guidance about how to coordinate the AT benefits that children are eligible to receive under both EPSDT and HCBS in order to comply with the regulation if the requested AT is not available to the child under EPSDT, the proposed manual language only says, “AT for individuals younger than 21 years of age must be accessed through the EPSDT benefit,” indicating children may only access AT under the EPSDT benefit.

Recommend revision: “AT for individuals younger than 21 years of age may be requested via a DD Waiver if the AT is not available to the child under EPSDT.”

Page 52 - Service Exclusions - 1^st Bullet
Comment:  Assumes all of the items listed will only ever be for the purposes of convenience, restraint, or recreational or leisure purposes. This administrative declaration circumvents and undermines the fundamental requirement for an independent, professional consultation/evaluation, and could restrict individuals from accessing the least expensive, most cost-effective manner of meeting the regulatory purpose of AT, “to enable individuals to increase abilities to perform ADLs; to perceive control, or communicate with their environment; to actively participate in other waiver services; or are necessary for the proper functioning (12VAC30-122-270)” of other equipment. As drafted, the manual permits service authorization staff to overrule the independent professional if any item related to those excluded, regardless of compliance with the regulations. Blanket exclusions are unnecessary and contradictory to the several pages of criteria, guidance, exclusions, and instructions in the manual that safeguard the AT fund for appropriate and compliant utilization.

Recommend deletion of the entire first bullet.

Page 53 - Last Bullet - Service Exclusions
Comment:  Same as regulation. Additional explanation or guidance would be appreciative. It is about duplication of payment for services that are reasonable accommodation requirements of the ADA and other Acts. What constitutes a duplication of payment? If an AT service is otherwise paid by whom? The HCBS AT budget? The Waiver? A Waiver provider? The State Plan? Another State entity? If the individual already has the AT that provides reasonable accommodation, then the independent professional would not recommend it as a needed item. Please describe a real-world example of a duplicate waiver payment for AT that supports this restriction.

Recommend revision with example that provides a better understanding of the regulation.

Page. 54 - Provider Documentation Requirements
Comment: states “Documentation in the Support Coordination record of notification by the individual or individual’s representative family/caregiver of satisfactory completion or receipt of the service or item.” This is supported in the regulations but is not a requirement that the AT provider can fulfill.

Recommend removing this bullet from the Provider Documentation Requirements and consider adding a separate Support Coordinator Requirements list and/or adding it to the Support Coordination Manual also currently open for public comment.

Page 54 Provider Documentation Requirements - Last Bullet -
Comment:  States for the “Support Coordinator to perform and document a face-to-face visit to assure that the individual can use the AT safely and appropriately.” Overly burdensome. This is not a requirement for provider documentation and is not supported in the regulations at (12VAC30-122-270). The other documentation requirements listed in the manual are copied from the regulations without additional detail or guidance, but this particular bullet does not reflect any requirement in the regulations for a face-to-face visit or assurance of safe and appropriate use. Only a professional trained in the AT item could make an assurance that the individual can use the AT safely and appropriately, which is part of the required independent professional consultation/evaluation.

Recommend deletion of the entire sentence.

Community Guide Services

Page 59 - 3rs Bullet - Documentation Requirements
Comment: States “Observations of the individual’s responses to the service must be available in at least a daily note”. Community Guide services are not necessarily provided on a daily basis.  Is this needed and realistic. Recommend deleting “daily” from note.

Electronic Home-Based Supports (EHBS)

General Comment:  The regs and the manual are aligned with one another in a way that only makes sense for equipment. In order for providers to deliver services under EHBS, the unit of service cannot be limited to only one.
Recommend Additional Language Be Added: "Only one unit of service is only appropriate for equipment or items that are delivered once. Services that include ongoing monitoring and other supports delivered electronically occur periodically and routinely as needed by the individual, similar to therapeutic consultation. Please consider separating administration of EHBS coverage of equipment from EHBS coverage of services to allow for appropriate and compliant service authorization and billing for ongoing services."

Page 63 - Service Documentation Requirements - Bullet #2
Comment:  This documentation is the requirement of the Support Coordinator and not the EHBS provider.

Individual and Family Caregiver Training

Page 70:
Indicates that contact notes, monthly notes, and quarterly reports must be completed. This is more than the regulations require.  Is also duplicative. It is also more information than is required for other services.  Other services require a quarterly review. Clarification is needed if monthly summaries are needed when there is a quarterly review being completed.

Transition Services

Page 74 Paragraph 1 and Page 75 Last Paragraph - Inconsistent language
Comment:  Page 74 includes language that an “individual has 30 days after transitioning to apply for Transition Services”.  Page 75 states that “service authorization must be obtained within 30 days of discharge.  Recommend clarification and consistent language be used to avoid confusion.

Benefits Planning
Page 90: Criteria/Allowable Activities
1^st Paragraph
Comment:  DELETE “or” before “employment status” and ADD “or need for work incentives”.

Page 94:
Paragraph 1:  Indicates that this service requires face to face contact.
Comment:  Regulations do not specify that this be a face-to-face contact.  Alternative options must be available including telehealth and virtual options. Overly prescriptive and not included in regulations.

Page 95: Mid-page - Bullet 1 -
Comment:  ADD “or is not available” after “have been explored and exhausted”.  Also, please clarify what documentation is needed to fulfill the requirement of “explored or exhausted”.

Page 95: Mid-page - Bullet 2 - Indicates there should be documentation of “All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS”
Comment:  Should also include “DSS and SSA as appropriate” for this particular service.

Community Engagement

Page 102 - Criteria/Allowable Activities
Paragraph 1 - Last Sentence
Comment:  Underlined sentence is confusing.  Should “community engagement” be substituted for “supported employment”?

Page 104 - 7^th Bullet:
Comment:  ADD “independent” before “living skills”

Group Day Services

Page 112 - Service Definition/Description
1^st Paragraph - Last Sentence:  DELETE “these services”.

Page 114:  Semi-Predictable Events
Paragraph 1:  States “The provider may request between 3-5 hours of additional “community engagement” per week that will allow the individual to choose additional community outings.
Comment:   Shouldn’t this read:  “The provider may request between 3-5 hours of additional “group day” services per week that will allow the individual to choose additional “group day” activities.  It is not clear.  If Community Engagement - then it should be included in the Community Engagement service section.

DD Waiver Manual - Chapter 4 - Part 2 of 2
30-Day Public Comment - vaACCSES

Supported Employment Services

Page 119: Criteria/Allowable Activities
Comment: 

• Recommend that bullets be entirely realigned AND be delineated between Individual SE and Group SE.
• The first sentence indicates that there is one element that is limited to ISE only. However, there are seven elements listed and are provided in GSE services. The “this element is limited…” should be at the end of the previous bullet.  It should state - “Individual job development, with or without the individual present that produces an appropriate job match for the individual and the employer to include job analysis or determining job tasks, or both. This element is limited to ISE only and is not permitted for GSE”
• Allowable activities should allow for reimbursement for collateral contacts, including Workplace Assistance if the service is provided. 
• Staff provision of transportation – need criteria for what is considered “unavailable or inaccessible” and how this is to be documented. 

• States - “For DMAS reimbursement to occur, the individual must be present, unless otherwise noted, when these activities occur:  Vocational or job-related discovery or assessment,

Supports to ensure the individual's health and safety during the hours of work”
Comment: We recommend that the above allowable activities be noted that these activities can be conducted without the individual being present.  In fact, many discovery and assessment documents are reviewed in the absence of the individual.  Furthermore, the coordination and logistics of arranging health and safety supports, such as coordination with the employment site or family members, would precede the implementation and therefore occur without the individual being present.

Page 120: Customized Employment
Comment:  There is nothing indicated in the manual regarding who may provide this service. Under DARS funded CE only ACRE Customized Employment certified specialists may provide this service – is this the expectation for DBHDS or can any ISE employment specialist provide it?

Page 120 - Job Search Planning
Comment:  the following “conduct an analysis of benefits which may be accessed through Benefits Planning” is unclear. Benefits planning is a separate service.  What is the “analysis of benefits” that is being referred to? While most employment specialists can identify when an individual would need that service, it is the role of the support coordinator to refer for the service and coordinate services.  

Page 122: Documentation of the Individual’s Ineligibility for SE Services
5^th Bullet:  States “Documentation of the individual’s ineligibility for supported employment service through DARS or IDEA, as applicable. If the individual is ineligible to receive service through IDEA, documentation is required only for lack of DARS funding. Acceptable documentation for the lack of DARS or IDEA funding would include a letter from either DARS or the local school system or a record of a telephone call, including name, date, and person contacted, documented either in the individual's file maintained by the support coordinator, on the ISP, or on the supported employment provider's supporting documentation. Unless the individual's circumstances change, for example, the individual is seeking a new job, the original verification may be forwarded into the current record or repeated on the supporting documentation on an annual basis”
Comment: We recommend that the responsibility for documenting Waiver ineligibility based on DARS or IDEA eligibility should be the responsibility of the Support Coordinator and should be indicated as a Support Coordinator responsibility instead of a provider responsibility.

Workplace Assistance

Page 124: Criteria/Allowable Activities
Comment:  ADD “This service is designed to support individuals in competitive, integrated positions for whom all options for independence in regards to appropriate job match, reasonable accommodations, and the utilization of natural supports in the workplace have been explored, exhausted and documented. This service is supplementary to individual supported employment in order to maintain stability in the workplace.”

Page 124 - Paragraph 1
Comment:  Includes a typo. Should read “has learned the basic skills…”

Additionally, there should be information under criteria indicating that natural supports and accommodations are not available for the identified support needs.

Skilled Nursing Services

Overall Comment - Page 140 - 2^nd to last bullet - There is a significant change in the Manual which is in conflict with the DD Waiver regulations regarding the period for which an authorization is completed.  The change is more prescriptive than the regulations and changes the 1-year authorization in line with an individual’s ISP year to a 6-month authorization. The Manual should not be more prescriptive than the regulations.  This places additional burden on providers. A change in this policy needs to go through the regulatory process or legislative process for full vetting.

Group Home Residential

Page 150 - Service Limitations

Comment:  Regulation 12VAC30-122-390 says “March 31, 2021” and the Manual says “May 1, 2021”  Consistency is needed between regulations and Manual.

Page 153 - 1^st Paragraph - Last Sentence

Comment:  Manual states “Each quarterly review will represent the quarterly data.  However, the fourth quarter will provide an annual summary in addition to the fourth quarter data.  This is not authorized in regulations.  Inconsistent.

Sponsored Residential
Page 175 - Last Bullet
Comment:  DELETE last sentence “Four written reviews span the entire ISP year.”  Language is not consistent with other residential services.

Consumer Directed Services & Services Facilitation

Page 203
Comment:  After the description of CD services in general, and before the beginning of what is currently on Page 204, we recommend that you add the following regulatory language in the Manual for clarification and consistency - 12VAC30-122-150, A, 2, d, e, and f

Page 204 - Bullet 1 --
Comment: Recommend clarification around whether or not the EOR must live with the individual receiving services.  Providers often get “pended” for this. 

Page 204 - Last paragraph -  After the first sentence, ADD “If the individual chooses not to have service facilitation, the support coordinator must document which family member or caregiver other than the EOR shall perform all of the duties and meet all of the requirements of a CD services facilitator.”  (VAC1230-122-150, A, 2, e)

Page 205 - Paragraph 3 - “When two individuals who live in the same home….”.  Recommend ADD “If the individual has chosen not to have Services Facilitation, then the family member or caregiver acting in that capacity will be responsible this assessment.”

Page 205 - Paragraph 4 - Recommend the first sentence to say “An individual who has chosen consumer direction may choose, at any time, to voluntarily change all or part of their services to the agency-directed model as long as he/she/they continues to qualify for the specific services.”
Comment:  For example, he/she/they may choose to move just Respite or part of the Personal Care hours to agency, while maintaining all, or a portion of their Personal Care under the consumer-directed model of service.”  Recommend the second sentence in that paragraph to read, “The services facilitator, or family member or caregiver acting in that capacity, and the support coordinator are responsible for assisting….”

Page 205 - Last bullet - If the change recommended above for Rec 1is adopted - this bullet can remain as is.

Page 207 - Paragraph 1 - This is the explanation that needs to be moved up or copied in the CD section above SF.  See recommendation #1.

Page 207 - Paragraph 3 - The second to last sentence in this part is not proper grammar. Recommend - “Transitions from the CCC Plus Waiver to a DD waiver will only occur only on the first day of a month.”  Also, the last sentence should read, “The SF, or family member or caregiver acting in that capacity, has a role to play in this process in order to ensure continuity of care.”

Page 207 - Last Section  Bullet 2 - there needs to be a space between the words "should" and "call" in the last sentence.

Page 208 - Bullet 5 - Recommend to read “For consumer-directed services, the services facilitator, or family member or caregiver acting in that capacity, must submit the Fiscal Agent Request Form to the FE/A and initiate the change in discal employer agent, if applicable, and the change from CCC Plus Waiver services to DD Waiver services.”

Page 209 - Last Bullet - Language is different from regulations - needs consistency and not more prescriptive language. The regs (12VAC30-122-500, B, 4) state “The services facilitator, during routine quarterly visits, shall also review and verify….”  The manual states “routine semi-annual visits”.  This language should be changed to match the regs. The manual should also add “or family member or caregiver acting in that capacity” to that sentence as well. 

Page 210 - Bullet 1 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must be available during standard business hours to the individual or EOR by telephone.”

Page 210 - Bullet 2 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, will assist the individual or EOR….”

Page 210 - Bullet 3 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must complete the assessments, ….”

Page 210 - Bullet 4 - Language inconsistent with regulations.  The regs (12VAC30-122-500, B, 8) state “Service facilitation service shall be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but at a minimum quarterly routine visits shall take place.”  The manual has been changed to say, “Services facilitation will be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but, at a minimum, routine semi-annual visits.” The manual should be changed to match the regs.  Also, the language “or family member or caregiver acting in that capacity” needs to be added. 

Page 210 - Last Sentence - Recommend language change to “The SF, or family member or caregiver acting in that capacity, may not be the individual enrolled….”

Page 211 - 1^st Sentence - Recommend language change to “The SF, or family member or caregiver acting in that capacity, must document….”

Page 211 - 2^nd Sentence - Recommend language change to “Should a CD employee not report for work or terminate employment without notice, the SF or family member or caregiver acting in that capacity, upon the individual’s or EOR’s request….”

Page 211 - Service Documentation & Requirements -

• 1^st Sentence - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must maintain….”
• Bullet 1  - Recommend language change to “his” to “his/her/they” in sentence, “….receipt of training on his responsibility for the accuracy….”
• Bullet 2  - Typo - "hat" should be "that"
• Bullet 3 -  What is considered a “contact”?  This needs clarification.  Also, what is considered “medical record

Page 212 - Bullet 2 -  
Comment:  Language in the Manual should match the regulations. The Manual Language is more prescriptive. The manual reads, “In a situation whereby the individual’s needs have changed significantly, the plan for supports must be reviewed by the provider.”  The regs (12VAC30-122-500, E, 3, g) state “Documentation indicating that desired outcomes and support activities of the plan for supports have been reviewed by the consumer-directed services facilitator provider quarterly, annually, and more often as needed.”  Manual pg 212, bullet 2, the sub-bullets à These sub-bullets do not exist in the regs.  Why are we being made to document MORE than what is in the regs???  Isn’t that considered more restrictive than the regs?

Page 212 - Bullet 3 - It is missing the number of calendar days in the language.  Also, there is no time limit in the regs, so any introduction of a time limit on when the review must be submitted to the Support Coordinator is more restrictive than the regs. 

Page 212 - Bullet 3 - Sub-Bullet 1 - There is no sub-bullet in the regulations.  This needs to be a dark bullet and moved to the left to align with the other bullets.

DD Waiver Manual - Chapter 6 - 30-Day Public Comment - vaACCSES

Quality Management and Utilization Reviews

Introduction
Page 1:

• First paragraph, 2^nd sentence - who is DMAS’s “designated agent”? Recommend clarification between DMAS QMR staff and any subcontracted contractor for financial audits, etc.
• First paragraph, 4^th sentence states “DMAS conducts compliance reviews on providers that are found to provide services in excess of established norms, ..."
  Comment:  Shouldn't this be just on those that do not provide services in accordance with the regulations?  What does "established norms" mean? Language needs to be changed or definition of “established norms” needs to be provided.

General Requirements
Page 1:

• Second paragraph, 1st sentence states "DMAS participation standards and policies".
  Comment:  Shouldn’t this refer to regulations as in the following sentence?  If “standards and policies” is retained - definition or citation needs to be included.

Page 2:

• 1^st sentence - general grammar problem - comma needed following the word "individuals”.
• Second paragraph, 1st sentence - Who is "staff"?  We assume “DMAS QMR staff” in this instance.
  Comment:  Helpful to state and delineate between DMAS QMR staff and provider staff within this paragraph and others to provide clarity. Also, "staff may request licenses” - However, not all providers are required to have staff that is licensed. Add “providers and staff required to have licenses”.  Differentiate between requirements of services that are licensed and services that are not licensed regarding criminal background checks and what “documentation” is required.

• Third paragraph, 2nd sentence - Again, the requirement to be in compliance with "DMAS provider agreements and policies"
  Comment:  Shouldn’t this refer to regulations?  If “standards and policies” is retained - definition or citation needs to be included for clarity.

• Fourth paragraph, 3rd sentence - Use of the word "provider" here. 
  Comment:  Assume this means the Agency Provider and not the Personal Care provider. However, “provider” is used interchangeably for both throughout document. “Staff” is also used interchangeably throughout the document. Clarity and specificity is needed consistently.

Page 3:

• Bullet 1, 1st sentence - states "within the program's guidelines"?  Should this be "in accordance with regulations"?
• Bullet 1, 2nd sentence - Same comment as above related to the use of the word "provider".
• Bullet 1, 3rd sentence -
  Comment:  What is considered to be "the individual's record"?  Add specific reference to what record.  Is it enough to document these things in a provider’s system?  Also, what is classified as "any substantial change"?  And what specific "documentation of such change" is required? Please add specificity.
• Bullet 1, 4th sentence - Recognize that provider’s responsibility to identify “substantial changes” and inform the Support Coordinator. 
  Comment:  However, it is the Support Coordinator’s role to obtain and coordinate those services that the individual requires to remain in the community and not the provider. The "or" that follows that requirement should be replaced with "so that the Support Coordinator can obtain any other services,...."
• Bullet 3, 2nd sentence - Clarity needed.
  Comment:  Who is considered "provider staff"?  and who is the "provider agency representative"?  In the case of Service Facilitation - clarity is needed since the SF is the one both in communication with the individual AND the one responsible for the oversight of the plan.
• Manual Pg 3, bullet 3, last sentence à where should the "providers" find the remaining list of quality of supports if this is just "some" of them?  Remember, not every provider is licensed, so we are only following the regulations and this handbook.
• Manual Pg 3, bullet 4 à are we allowed to use electronic signature now?  Where did that change in the regulations?

Page 4:

• Bullet 1 - Use of "provider" again and "maintain a record"? 
  Comment:  Can that be just be in the provider’s system?  It's confusing since the next sentence mentions the forms.  So is the "record" the "form"?  Are those one and the same?  Why not use the same word for both spots?
• 1st full paragraph - "DMAS will review the provider's performance in all the outcome areas to determine the provider's ability to achieve high quality supports..." 
  Comment:  This is where that word "provider" gets used interchangeably again.  The SF writes outcomes based on the Part 3, but the outcomes are for the Personal Care Attendant to provide to the individual and not for the SF to provide to the individual.  So, who is the "provider" whose performance DMAS is reviewing? Further clarification is needed.
• General Comment on consistency - The language is now referring to DMAS.  "DMAS will review", "DMAS will evaluate", "DMAS may require".  Before, in this same document, it refers to "staff".  Consistency is needed throughout.
• 2nd full paragraph - Shouldn’t the regulations be mentioned here instead of “policies and procedures”?
• Bullet 1 - Further clarity is needed.  What exactly is meant by "periodically"?
• Bullet 5, sentence 1  - A sentence is needed to differentiate Service Facilitation and CD services from other services and their specific requirements. States "Staff" will meet with at least one individual or PCG to determine satisfaction with the provider.  Which provider is that?  The SF provider agency?  Or the PCA provider?  Not clear regarding what would be measured for SF. 

Page 5:

• Bullet 1 - why is "provider" underlined?  Who is "staff"?  Appreciate the reference to regulations vs “policies and procedures”.   
• Bullet 3  - Who is submitting this letter to these other agencies? Specificity needed.

Comprehensive and Ongoing Assessment and Planning

Page 8:  Bullet 1, sub-bullet 5 - A parenthesis is missing here.

Page 10: Bullet 3 - Why is "the waiver enrollment date" underlined?

Services are Delivered, Reviewed and Modified as Needed
Page 11:   
Comment:  Is this for all providers or specific to Case Management?  The first bullet/sub-bullet seems to speak to each service provider, but then the second sub-bullet is specific to Case Management.  Then the third sub-bullet goes back to "each service provider".  Recommend to separate and list bullets under either provider and case management for clarity

Page 12:  Main Bullet
Comment:  Sub-bullet 1 - Provide specificity in Manual. What DMAS form is to be used for the quarterly review?  There is currently no consistency from CSB to CSB on what documentation is required to be used for quarterlies.  There is also no consistency as to what has to be in that quarterly review.  Specificity would be helpful to provide consistency.

Page 13: 

• 1st sub-bullet à "All providers must be invited to the meeting and participate in the development of the new ISP annually."  Are SF required to be present at the meeting?  Service Facilitators are not compensated for this meeting and can only bill for a reassessment visit. These meetings can be up to 3+ hours.

Services Delivered are Consistent With Service Limits
Page 13:  Bullet 1, sub-bullet 2 -
Comment:  Need additional specificity for Service Facilitation - recommend separate sub-bullet. "The number of hours does require authorization."  What hours?  MT Units?  PCA hours?  Respite Hours?  Companion Hours?  The hours the SF is working?

Page 15: Bullet 2
Comment:  Paper timesheets went away a long time ago, so the EOR and employee will not be signing them.  Time is either logged via app, online portal, or by calling in using IVR.  So billing for CD services will not be supported by a timesheet that is signed.  This point in the manual needs to be removed.

Support Coordinator/Case Manager/Provider Responsibilities
Page 23:
Comment:  Need to REMOVE “Provider” from this section. “Provider” should not be included in this title when the first paragraph says that the following things are the responsibility of the support coordinator/case manager, and doesn't mention the provider?  None of the things listed are the responsibility of the provider. 

DD Waiver Manual - Chapter 6 - 30-Day Public Comment - vaACCSES

Quality Management and Utilization Reviews

Introduction
Page 1:

• First paragraph, 2^nd sentence - who is DMAS’s “designated agent”? Recommend clarification between DMAS QMR staff and any subcontracted contractor for financial audits, etc.
• First paragraph, 4^th sentence states “DMAS conducts compliance reviews on providers that are found to provide services in excess of established norms, ..."
  Comment:  Shouldn't this be just on those that do not provide services in accordance with the regulations?  What does "established norms" mean? Language needs to be changed or definition of “established norms” needs to be provided.

General Requirements
Page 1:

• Second paragraph, 1st sentence states "DMAS participation standards and policies".
  Comment:  Shouldn’t this refer to regulations as in the following sentence?  If “standards and policies” is retained - definition or citation needs to be included.

Page 2:

• 1^st sentence - general grammar problem - comma needed following the word "individuals”.
• Second paragraph, 1st sentence - Who is "staff"?  We assume “DMAS QMR staff” in this instance.
  Comment:  Helpful to state and delineate between DMAS QMR staff and provider staff within this paragraph and others to provide clarity. Also, "staff may request licenses” - However, not all providers are required to have staff that is licensed. Add “providers and staff required to have licenses”.  Differentiate between requirements of services that are licensed and services that are not licensed regarding criminal background checks and what “documentation” is required.

• Third paragraph, 2nd sentence - Again, the requirement to be in compliance with "DMAS provider agreements and policies"
  Comment:  Shouldn’t this refer to regulations?  If “standards and policies” is retained - definition or citation needs to be included for clarity.

• Fourth paragraph, 3rd sentence - Use of the word "provider" here. 
  Comment:  Assume this means the Agency Provider and not the Personal Care provider. However, “provider” is used interchangeably for both throughout document. “Staff” is also used interchangeably throughout the document. Clarity and specificity is needed consistently.

Page 3:

• Bullet 1, 1st sentence - states "within the program's guidelines"?  Should this be "in accordance with regulations"?
• Bullet 1, 2nd sentence - Same comment as above related to the use of the word "provider".
• Bullet 1, 3rd sentence -
  Comment:  What is considered to be "the individual's record"?  Add specific reference to what record.  Is it enough to document these things in a provider’s system?  Also, what is classified as "any substantial change"?  And what specific "documentation of such change" is required? Please add specificity.
• Bullet 1, 4th sentence - Recognize that provider’s responsibility to identify “substantial changes” and inform the Support Coordinator. 
  Comment:  However, it is the Support Coordinator’s role to obtain and coordinate those services that the individual requires to remain in the community and not the provider. The "or" that follows that requirement should be replaced with "so that the Support Coordinator can obtain any other services,...."
• Bullet 3, 2nd sentence - Clarity needed.
  Comment:  Who is considered "provider staff"?  and who is the "provider agency representative"?  In the case of Service Facilitation - clarity is needed since the SF is the one both in communication with the individual AND the one responsible for the oversight of the plan.
• Manual Pg 3, bullet 3, last sentence à where should the "providers" find the remaining list of quality of supports if this is just "some" of them?  Remember, not every provider is licensed, so we are only following the regulations and this handbook.
• Manual Pg 3, bullet 4 à are we allowed to use electronic signature now?  Where did that change in the regulations?

Page 4:

• Bullet 1 - Use of "provider" again and "maintain a record"? 
  Comment:  Can that be just be in the provider’s system?  It's confusing since the next sentence mentions the forms.  So is the "record" the "form"?  Are those one and the same?  Why not use the same word for both spots?
• 1st full paragraph - "DMAS will review the provider's performance in all the outcome areas to determine the provider's ability to achieve high quality supports..." 
  Comment:  This is where that word "provider" gets used interchangeably again.  The SF writes outcomes based on the Part 3, but the outcomes are for the Personal Care Attendant to provide to the individual and not for the SF to provide to the individual.  So, who is the "provider" whose performance DMAS is reviewing? Further clarification is needed.
• General Comment on consistency - The language is now referring to DMAS.  "DMAS will review", "DMAS will evaluate", "DMAS may require".  Before, in this same document, it refers to "staff".  Consistency is needed throughout.
• 2nd full paragraph - Shouldn’t the regulations be mentioned here instead of “policies and procedures”?
• Bullet 1 - Further clarity is needed.  What exactly is meant by "periodically"?
• Bullet 5, sentence 1  - A sentence is needed to differentiate Service Facilitation and CD services from other services and their specific requirements. States "Staff" will meet with at least one individual or PCG to determine satisfaction with the provider.  Which provider is that?  The SF provider agency?  Or the PCA provider?  Not clear regarding what would be measured for SF. 

Page 5:

• Bullet 1 - why is "provider" underlined?  Who is "staff"?  Appreciate the reference to regulations vs “policies and procedures”.   
• Bullet 3  - Who is submitting this letter to these other agencies? Specificity needed.

Comprehensive and Ongoing Assessment and Planning

Page 8:  Bullet 1, sub-bullet 5 - A parenthesis is missing here.

Page 10: Bullet 3 - Why is "the waiver enrollment date" underlined?

Services are Delivered, Reviewed and Modified as Needed
Page 11:   
Comment:  Is this for all providers or specific to Case Management?  The first bullet/sub-bullet seems to speak to each service provider, but then the second sub-bullet is specific to Case Management.  Then the third sub-bullet goes back to "each service provider".  Recommend to separate and list bullets under either provider and case management for clarity

Page 12:  Main Bullet
Comment:  Sub-bullet 1 - Provide specificity in Manual. What DMAS form is to be used for the quarterly review?  There is currently no consistency from CSB to CSB on what documentation is required to be used for quarterlies.  There is also no consistency as to what has to be in that quarterly review.  Specificity would be helpful to provide consistency.

Page 13: 

• 1st sub-bullet à "All providers must be invited to the meeting and participate in the development of the new ISP annually."  Are SF required to be present at the meeting?  Service Facilitators are not compensated for this meeting and can only bill for a reassessment visit. These meetings can be up to 3+ hours.

Services Delivered are Consistent With Service Limits
Page 13:  Bullet 1, sub-bullet 2 -
Comment:  Need additional specificity for Service Facilitation - recommend separate sub-bullet. "The number of hours does require authorization."  What hours?  MT Units?  PCA hours?  Respite Hours?  Companion Hours?  The hours the SF is working?

Page 15: Bullet 2
Comment:  Paper timesheets went away a long time ago, so the EOR and employee will not be signing them.  Time is either logged via app, online portal, or by calling in using IVR.  So billing for CD services will not be supported by a timesheet that is signed.  This point in the manual needs to be removed.

Support Coordinator/Case Manager/Provider Responsibilities
Page 23:
Comment:  Need to REMOVE “Provider” from this section. “Provider” should not be included in this title when the first paragraph says that the following things are the responsibility of the support coordinator/case manager, and doesn't mention the provider?  None of the things listed are the responsibility of the provider. 

DD Waiver Manual - Chapter 4 - Part 1 of 2
30-Day Public Comment - vaACCSES

GENERAL COMMENTS:

1. Purpose of Manual to provide explanation, clarification, definition, examples, possible service scenarios, and interpretation for providers to deliver consistent implementation of quality services, documentation and required reports across the Commonwealth. However, we have found that there are numerous items in the Manual that are more prescriptive than what is included within DD Waiver regulatory authority - which is problematic. The Manual should not be more prescriptive than regulations since the governing authority are the regs. The addition of regulatory citations would help as reference throughout the Manual as appropriate. 
2. Consistency between Regulations and Manual is critical.  There are multiple examples throughout the Manual of inconsistencies between licensing regulations, DD Waiver regulations and what’s required by DMAS in the Provider Agreement.  All of this makes it confusing for the provider and creates additional administrative burden.  It also complicates the rules for providers that provide “unlicensed services”.  Because the service is unlicensed, it makes it difficult to know and fulfill requirements that refer to the licensing regulations and/or to forms referenced.
3. Chart with “Corresponding Regulations” and BI, FI and CL columns are a helpful visual and provide clarity regarding regulation reference at the beginning of each service.  We recommend that a chart be used for all services in Chapter 4. (See page 78 as example).
4. There is an overall need to clearly delineate the responsibilities and requirements for support coordinator actions versus service provider actions.  Ideally, support coordination would either have a companion Manual or minimally, within the Waiver manual, have clear sections within chapters and/or services. Possibly, even a separate chapter with ONLY the Support Coordination requirements and responsibilities. The lack of separation and specificity are confusing regarding responsibility and requirements of “providers” throughout the Manual.  The question asked often throughout is “which provider is responsible”.
5. We request that overall instructions on how providers should round any fractions of service hours provided for billing purposes. This is not included in the current Manual but would be very helpful as an overall instruction to provide specification and consistency. In the past when we asked, we were told that these instructions were to be included in the future Manual in a chapter for “other services”.  It would of course be efficient to include this information within the Waiver manual.

CHAPTER 4:

Table of Contents & Service Option Charts:
Corrections Needed:

• Individual & Family/Caregiver Training is incorrectly marked as included in the BI waiver - should be FIS Waiver
• Workplace Assistance Services is incorrectly marked as only being included in the FIS Waiver - it is also included in the CL Waiver.

Page 1 - Criteria to Be Eligible -
Comment:  What if they do not have "functional limitations in major life activities" - but might need Companion Care or Sensory Equipment (AT or DME)?

Diagnostic Eligibility

Page 2, paragraph 1:
COMMENT:  Correction Needed. Paragraph refers to “three of more criteria described in (1) through (5) above…”  Please change bullets to numbers for clarity.

Day Assessment Service Authorization Requests

Page 22:

Comment:  Would prefer that the language used provide additional clarity than the 60-day assessment is an option (“may”) - but not required. Recommend - “Provider has the option to request a 60-day assessment prior to initiating plan for supports.”

Page 23:  Provider Discontinuation of Services.

Comment: Regarding 10 business days advanced notice in writing. This is not always possible. Individual Supported Employment (ISE) services, for example, will end when an individual quits or is terminated from a position and DARS categories are open. Would prefer language that better reflects that this is best practice when possible but not required. Additionally, it indicates that in a situation in which health/safety concerns are the reason for discharge, DBHDS must be notified – who at DBHDS is to be notified?

Assistive Technology (AT)  

General Comment: Assistive Technology (AT) is an HCBS waiver benefit that all recipients of DD waivers and CCC+ waivers are equally entitled to access in accordance with regulations at 12VAC30-122-270. Although there is only one regulation for AT, guidance for administration of it is inconsistent. AT requests for people with a DD waiver are approved by DBHDS according to the DD Waiver Manual Chapter IV and AT requests for people with the CCC+ waiver are approved by the MCO or KePRO according to the Durable Medical Equipment (DME) and Supplies Manual Chapter IV. Review of both manuals find extensive differences and variations, and both manuals are more restrictive than the AT regulations they are purported to clarify.

These contradictions and inconsistencies represent the root causes of many of the barriers that individuals, providers, and DMAS are experiencing as reported by the HB2197 working group that DMAS was charged with hosting to identify barriers to accessing AT and related services as well as options for removing them. Making the administrative manual changes recommended below will remove many of these barriers that impact over 30,000 people with disabilities. Only the DD Waiver Manual is open for public comment; the DME Manual was closed in June 2021 after receiving zero comments. We strongly urge DMAS to revise both Manuals to appropriately reflect the AT regulations at 12VAC30-122-270. Suggested revisions for both manuals are provided below.

Relevant Regs at 12VAC30-122-270.

Page 49 - Service Description - 2^nd to last sentence
Comment:  “Assistive technology devices are portable and authorized per calendar year” is inconsistent with the regulations, which do not require AT devices to be portable. Recommend DELETE “are portable and” to retain the calendar year portion of the sentence, which is consistent with the regulations.

Page 50 - Examples - Allowable Equipment Table

Comment:  Lists allowable equipment and activities that may include a limited list that does not fully reflect the allowable scope of AT in the regs because it lists both types of AT and purposes of AT. Specifically, the allowable list in the manual does not reference AT that enables an individual to actively participate in other waiver services. This purpose of AT is referenced in both the regulations and in the manual on the previous page that lists what AT is supposed to enable.

Recommend replacing the allowable equipment and services list on page 50 about the types of allowable AT to, “Allowable equipment and activities may include specialized medical equipment and ancillary equipment; durable or nondurable medical equipment and supplies; adaptive devices, appliances, and controls; and other equipment, devices, items, and software that meets the service definition.”

Page 51

Comment: This is a stand-alone exclusion that is neither supported by the regs nor referenced in the allowable items section of the regs or the manual, “Items such as furniture shall not be approved if they are of general utility and are not of direct medical benefit.” The regulations require an independent professional consultation that should determine on its own merit if the AT is needed to, “enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, or to participate in other waiver services. (12VAC30-122-270),” in order for the AT to be approved, making this additional stipulation unnecessary.

Recommend deletion of the entire sentence.

Page 51 -
Comment:  Sentence about software compatibility is more restrictive than regulations, “AT providers must ensure that requests for software are compatible with the individual’s current computer.” This assumes all individuals have a computer at all, let alone one that is compatible with every type of software that might be evaluated as necessary AT by an independent professional’s recommendation. The regulations are clear that the independent professional shall determine the most appropriate item(s) for the individual’s needs, which may be compatible with a device that they already own or may require upgrades, enhancements, or a separate device.

Recommend deletion of the entire sentence.

Page 51 - Service Units and Service Limitations - 1^st Bullet
Comment: “for a specific timeframe” does not clarify the implementation of the regulation. The only timeframe specified in the regulations at (12VAC30-122-270) is the budget limit for a calendar year, and many prior authorization systems only accept a 1-month service period for the AT code used for service authorization requests.

Recommend either deleting “for a specific timeframe” or revising to, “for the timeframe specified by the service authorization system.”

Page 52 - Service Units and Service Limitations Bullet about AT

Comment: under EPSDT for children is vague, confusing, and is more restrictive than the regulation. The regulation at (12VAC30-122-270) C.4. Service units and limitations says, “Requests for AT service via a DD Waiver shall be denied if the AT service is available under EPSDT.” Nowhere in any of the regulations are children under 21 limited to only AT available under EPSDT. Instead of instructions and guidance about how to coordinate the AT benefits that children are eligible to receive under both EPSDT and HCBS in order to comply with the regulation if the requested AT is not available to the child under EPSDT, the proposed manual language only says, “AT for individuals younger than 21 years of age must be accessed through the EPSDT benefit,” indicating children may only access AT under the EPSDT benefit.

Recommend revision: “AT for individuals younger than 21 years of age may be requested via a DD Waiver if the AT is not available to the child under EPSDT.”

Page 52 - Service Exclusions - 1^st Bullet
Comment:  Assumes all of the items listed will only ever be for the purposes of convenience, restraint, or recreational or leisure purposes. This administrative declaration circumvents and undermines the fundamental requirement for an independent, professional consultation/evaluation, and could restrict individuals from accessing the least expensive, most cost-effective manner of meeting the regulatory purpose of AT, “to enable individuals to increase abilities to perform ADLs; to perceive control, or communicate with their environment; to actively participate in other waiver services; or are necessary for the proper functioning (12VAC30-122-270)” of other equipment. As drafted, the manual permits service authorization staff to overrule the independent professional if any item related to those excluded, regardless of compliance with the regulations. Blanket exclusions are unnecessary and contradictory to the several pages of criteria, guidance, exclusions, and instructions in the manual that safeguard the AT fund for appropriate and compliant utilization.

Recommend deletion of the entire first bullet.

Page 53 - Last Bullet - Service Exclusions
Comment:  Same as regulation. Additional explanation or guidance would be appreciative. It is about duplication of payment for services that are reasonable accommodation requirements of the ADA and other Acts. What constitutes a duplication of payment? If an AT service is otherwise paid by whom? The HCBS AT budget? The Waiver? A Waiver provider? The State Plan? Another State entity? If the individual already has the AT that provides reasonable accommodation, then the independent professional would not recommend it as a needed item. Please describe a real-world example of a duplicate waiver payment for AT that supports this restriction.

Recommend revision with example that provides a better understanding of the regulation.

Page. 54 - Provider Documentation Requirements
Comment: states “Documentation in the Support Coordination record of notification by the individual or individual’s representative family/caregiver of satisfactory completion or receipt of the service or item.” This is supported in the regulations but is not a requirement that the AT provider can fulfill.

Recommend removing this bullet from the Provider Documentation Requirements and consider adding a separate Support Coordinator Requirements list and/or adding it to the Support Coordination Manual also currently open for public comment.

Page 54 Provider Documentation Requirements - Last Bullet -
Comment:  States for the “Support Coordinator to perform and document a face-to-face visit to assure that the individual can use the AT safely and appropriately.” Overly burdensome. This is not a requirement for provider documentation and is not supported in the regulations at (12VAC30-122-270). The other documentation requirements listed in the manual are copied from the regulations without additional detail or guidance, but this particular bullet does not reflect any requirement in the regulations for a face-to-face visit or assurance of safe and appropriate use. Only a professional trained in the AT item could make an assurance that the individual can use the AT safely and appropriately, which is part of the required independent professional consultation/evaluation.

Recommend deletion of the entire sentence.

Community Guide Services

Page 59 - 3rs Bullet - Documentation Requirements
Comment: States “Observations of the individual’s responses to the service must be available in at least a daily note”. Community Guide services are not necessarily provided on a daily basis.  Is this needed and realistic. Recommend deleting “daily” from note.

Electronic Home-Based Supports (EHBS)

General Comment:  The regs and the manual are aligned with one another in a way that only makes sense for equipment. In order for providers to deliver services under EHBS, the unit of service cannot be limited to only one.
Recommend Additional Language Be Added: "Only one unit of service is only appropriate for equipment or items that are delivered once. Services that include ongoing monitoring and other supports delivered electronically occur periodically and routinely as needed by the individual, similar to therapeutic consultation. Please consider separating administration of EHBS coverage of equipment from EHBS coverage of services to allow for appropriate and compliant service authorization and billing for ongoing services."

Page 63 - Service Documentation Requirements - Bullet #2
Comment:  This documentation is the requirement of the Support Coordinator and not the EHBS provider.

Individual and Family Caregiver Training

Page 70:
Indicates that contact notes, monthly notes, and quarterly reports must be completed. This is more than the regulations require.  Is also duplicative. It is also more information than is required for other services.  Other services require a quarterly review. Clarification is needed if monthly summaries are needed when there is a quarterly review being completed.

Transition Services

Page 74 Paragraph 1 and Page 75 Last Paragraph - Inconsistent language
Comment:  Page 74 includes language that an “individual has 30 days after transitioning to apply for Transition Services”.  Page 75 states that “service authorization must be obtained within 30 days of discharge.  Recommend clarification and consistent language be used to avoid confusion.

Benefits Planning
Page 90: Criteria/Allowable Activities
1^st Paragraph
Comment:  DELETE “or” before “employment status” and ADD “or need for work incentives”.

Page 94:
Paragraph 1:  Indicates that this service requires face to face contact.
Comment:  Regulations do not specify that this be a face-to-face contact.  Alternative options must be available including telehealth and virtual options. Overly prescriptive and not included in regulations.

Page 95: Mid-page - Bullet 1 -
Comment:  ADD “or is not available” after “have been explored and exhausted”.  Also, please clarify what documentation is needed to fulfill the requirement of “explored or exhausted”.

Page 95: Mid-page - Bullet 2 - Indicates there should be documentation of “All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS”
Comment:  Should also include “DSS and SSA as appropriate” for this particular service.

Community Engagement

Page 102 - Criteria/Allowable Activities
Paragraph 1 - Last Sentence
Comment:  Underlined sentence is confusing.  Should “community engagement” be substituted for “supported employment”?

Page 104 - 7^th Bullet:
Comment:  ADD “independent” before “living skills”

Group Day Services

Page 112 - Service Definition/Description
1^st Paragraph - Last Sentence:  DELETE “these services”.

Page 114:  Semi-Predictable Events
Paragraph 1:  States “The provider may request between 3-5 hours of additional “community engagement” per week that will allow the individual to choose additional community outings.
Comment:   Shouldn’t this read:  “The provider may request between 3-5 hours of additional “group day” services per week that will allow the individual to choose additional “group day” activities.  It is not clear.  If Community Engagement - then it should be included in the Community Engagement service section.

DD Waiver Manual - Chapter 4 - Part 2 of 2
30-Day Public Comment - vaACCSES

Supported Employment Services

Page 119: Criteria/Allowable Activities
Comment: 

• Recommend that bullets be entirely realigned AND be delineated between Individual SE and Group SE.
• The first sentence indicates that there is one element that is limited to ISE only. However, there are seven elements listed and are provided in GSE services. The “this element is limited…” should be at the end of the previous bullet.  It should state - “Individual job development, with or without the individual present that produces an appropriate job match for the individual and the employer to include job analysis or determining job tasks, or both. This element is limited to ISE only and is not permitted for GSE”
• Allowable activities should allow for reimbursement for collateral contacts, including Workplace Assistance if the service is provided. 
• Staff provision of transportation – need criteria for what is considered “unavailable or inaccessible” and how this is to be documented. 

• States - “For DMAS reimbursement to occur, the individual must be present, unless otherwise noted, when these activities occur:  Vocational or job-related discovery or assessment,

Supports to ensure the individual's health and safety during the hours of work”
Comment: We recommend that the above allowable activities be noted that these activities can be conducted without the individual being present.  In fact, many discovery and assessment documents are reviewed in the absence of the individual.  Furthermore, the coordination and logistics of arranging health and safety supports, such as coordination with the employment site or family members, would precede the implementation and therefore occur without the individual being present.

Page 120: Customized Employment
Comment:  There is nothing indicated in the manual regarding who may provide this service. Under DARS funded CE only ACRE Customized Employment certified specialists may provide this service – is this the expectation for DBHDS or can any ISE employment specialist provide it?

Page 120 - Job Search Planning
Comment:  the following “conduct an analysis of benefits which may be accessed through Benefits Planning” is unclear. Benefits planning is a separate service.  What is the “analysis of benefits” that is being referred to? While most employment specialists can identify when an individual would need that service, it is the role of the support coordinator to refer for the service and coordinate services.  

Page 122: Documentation of the Individual’s Ineligibility for SE Services
5^th Bullet:  States “Documentation of the individual’s ineligibility for supported employment service through DARS or IDEA, as applicable. If the individual is ineligible to receive service through IDEA, documentation is required only for lack of DARS funding. Acceptable documentation for the lack of DARS or IDEA funding would include a letter from either DARS or the local school system or a record of a telephone call, including name, date, and person contacted, documented either in the individual's file maintained by the support coordinator, on the ISP, or on the supported employment provider's supporting documentation. Unless the individual's circumstances change, for example, the individual is seeking a new job, the original verification may be forwarded into the current record or repeated on the supporting documentation on an annual basis”
Comment: We recommend that the responsibility for documenting Waiver ineligibility based on DARS or IDEA eligibility should be the responsibility of the Support Coordinator and should be indicated as a Support Coordinator responsibility instead of a provider responsibility.

Workplace Assistance

Page 124: Criteria/Allowable Activities
Comment:  ADD “This service is designed to support individuals in competitive, integrated positions for whom all options for independence in regards to appropriate job match, reasonable accommodations, and the utilization of natural supports in the workplace have been explored, exhausted and documented. This service is supplementary to individual supported employment in order to maintain stability in the workplace.”

Page 124 - Paragraph 1
Comment:  Includes a typo. Should read “has learned the basic skills…”

Additionally, there should be information under criteria indicating that natural supports and accommodations are not available for the identified support needs.

Skilled Nursing Services

Overall Comment - Page 140 - 2^nd to last bullet - There is a significant change in the Manual which is in conflict with the DD Waiver regulations regarding the period for which an authorization is completed.  The change is more prescriptive than the regulations and changes the 1-year authorization in line with an individual’s ISP year to a 6-month authorization. The Manual should not be more prescriptive than the regulations.  This places additional burden on providers. A change in this policy needs to go through the regulatory process or legislative process for full vetting.

Group Home Residential

Page 150 - Service Limitations

Comment:  Regulation 12VAC30-122-390 says “March 31, 2021” and the Manual says “May 1, 2021”  Consistency is needed between regulations and Manual.

Page 153 - 1^st Paragraph - Last Sentence

Comment:  Manual states “Each quarterly review will represent the quarterly data.  However, the fourth quarter will provide an annual summary in addition to the fourth quarter data.  This is not authorized in regulations.  Inconsistent.

Sponsored Residential
Page 175 - Last Bullet
Comment:  DELETE last sentence “Four written reviews span the entire ISP year.”  Language is not consistent with other residential services.

Consumer Directed Services & Services Facilitation

Page 203
Comment:  After the description of CD services in general, and before the beginning of what is currently on Page 204, we recommend that you add the following regulatory language in the Manual for clarification and consistency - 12VAC30-122-150, A, 2, d, e, and f

Page 204 - Bullet 1 --
Comment: Recommend clarification around whether or not the EOR must live with the individual receiving services.  Providers often get “pended” for this. 

Page 204 - Last paragraph -  After the first sentence, ADD “If the individual chooses not to have service facilitation, the support coordinator must document which family member or caregiver other than the EOR shall perform all of the duties and meet all of the requirements of a CD services facilitator.”  (VAC1230-122-150, A, 2, e)

Page 205 - Paragraph 3 - “When two individuals who live in the same home….”.  Recommend ADD “If the individual has chosen not to have Services Facilitation, then the family member or caregiver acting in that capacity will be responsible this assessment.”

Page 205 - Paragraph 4 - Recommend the first sentence to say “An individual who has chosen consumer direction may choose, at any time, to voluntarily change all or part of their services to the agency-directed model as long as he/she/they continues to qualify for the specific services.”
Comment:  For example, he/she/they may choose to move just Respite or part of the Personal Care hours to agency, while maintaining all, or a portion of their Personal Care under the consumer-directed model of service.”  Recommend the second sentence in that paragraph to read, “The services facilitator, or family member or caregiver acting in that capacity, and the support coordinator are responsible for assisting….”

Page 205 - Last bullet - If the change recommended above for Rec 1is adopted - this bullet can remain as is.

Page 207 - Paragraph 1 - This is the explanation that needs to be moved up or copied in the CD section above SF.  See recommendation #1.

Page 207 - Paragraph 3 - The second to last sentence in this part is not proper grammar. Recommend - “Transitions from the CCC Plus Waiver to a DD waiver will only occur only on the first day of a month.”  Also, the last sentence should read, “The SF, or family member or caregiver acting in that capacity, has a role to play in this process in order to ensure continuity of care.”

Page 207 - Last Section  Bullet 2 - there needs to be a space between the words "should" and "call" in the last sentence.

Page 208 - Bullet 5 - Recommend to read “For consumer-directed services, the services facilitator, or family member or caregiver acting in that capacity, must submit the Fiscal Agent Request Form to the FE/A and initiate the change in discal employer agent, if applicable, and the change from CCC Plus Waiver services to DD Waiver services.”

Page 209 - Last Bullet - Language is different from regulations - needs consistency and not more prescriptive language. The regs (12VAC30-122-500, B, 4) state “The services facilitator, during routine quarterly visits, shall also review and verify….”  The manual states “routine semi-annual visits”.  This language should be changed to match the regs. The manual should also add “or family member or caregiver acting in that capacity” to that sentence as well. 

Page 210 - Bullet 1 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must be available during standard business hours to the individual or EOR by telephone.”

Page 210 - Bullet 2 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, will assist the individual or EOR….”

Page 210 - Bullet 3 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must complete the assessments, ….”

Page 210 - Bullet 4 - Language inconsistent with regulations.  The regs (12VAC30-122-500, B, 8) state “Service facilitation service shall be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but at a minimum quarterly routine visits shall take place.”  The manual has been changed to say, “Services facilitation will be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but, at a minimum, routine semi-annual visits.” The manual should be changed to match the regs.  Also, the language “or family member or caregiver acting in that capacity” needs to be added. 

Page 210 - Last Sentence - Recommend language change to “The SF, or family member or caregiver acting in that capacity, may not be the individual enrolled….”

Page 211 - 1^st Sentence - Recommend language change to “The SF, or family member or caregiver acting in that capacity, must document….”

Page 211 - 2^nd Sentence - Recommend language change to “Should a CD employee not report for work or terminate employment without notice, the SF or family member or caregiver acting in that capacity, upon the individual’s or EOR’s request….”

Page 211 - Service Documentation & Requirements -

• 1^st Sentence - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must maintain….”
• Bullet 1  - Recommend language change to “his” to “his/her/they” in sentence, “….receipt of training on his responsibility for the accuracy….”
• Bullet 2  - Typo - "hat" should be "that"
• Bullet 3 -  What is considered a “contact”?  This needs clarification.  Also, what is considered “medical record

Page 212 - Bullet 2 -  
Comment:  Language in the Manual should match the regulations. The Manual Language is more prescriptive. The manual reads, “In a situation whereby the individual’s needs have changed significantly, the plan for supports must be reviewed by the provider.”  The regs (12VAC30-122-500, E, 3, g) state “Documentation indicating that desired outcomes and support activities of the plan for supports have been reviewed by the consumer-directed services facilitator provider quarterly, annually, and more often as needed.”  Manual pg 212, bullet 2, the sub-bullets à These sub-bullets do not exist in the regs.  Why are we being made to document MORE than what is in the regs???  Isn’t that considered more restrictive than the regs?

Page 212 - Bullet 3 - It is missing the number of calendar days in the language.  Also, there is no time limit in the regs, so any introduction of a time limit on when the review must be submitted to the Support Coordinator is more restrictive than the regs. 

Page 212 - Bullet 3 - Sub-Bullet 1 - There is no sub-bullet in the regulations.  This needs to be a dark bullet and moved to the left to align with the other bullets.  

COMMENTS ON ASSISTIVE TECHNOLOGY (AT) IN THE DD WAIVER MANUAL CHAPTER IV General Comment: Assistive Technology (AT) is an HCBS waiver benefit that all recipients of DD waivers and CCC+ waivers are equally entitled to access in accordance with regulations at 12VAC30-122-270. Although there is only one regulation for AT, guidance for administration of it is inconsistent. AT requests for people with a DD waiver are approved by DBHDS according to the DD Waiver Manual Chapter IV and AT requests for people with the CCC+ waiver are approved by the MCO or KePRO according to the Durable Medical Equipment (DME) and Supplies Manual Chapter IV. Review of both manuals find extensive differences and variations, and both manuals are more restrictive than the AT regulations they are purported to clarify. These contradictions and inconsistencies represent the root causes of many of the barriers individuals, providers, and DMAS are experiencing as reported by the HB2197 working group that DMAS was charged with hosting to identify barriers to accessing AT and related services as well as options for removing them. Making the administrative manual changes recommended below will remove many of these barriers that impact over 30,000 people with disabilities. Only the DD Waiver Manual is open for public comment; the DME Manual was closed in June 2021 after receiving zero comments. We strongly urge DMAS to revise both Manuals to appropriately reflect the AT regulations at 12VAC30-122-270 in order to remove many systemic barriers to assistive technology access. Suggested revisions for both manuals are provided below. DD Waivers Manual, IV, Assistive Technology Regulations 12VAC30-122-270 • Pg. 49, “Assistive technology devices are portable and authorized per calendar year” is inconsistent with the regulations, which do not require AT devices to be portable. o Recommend deleting “are portable and” to retain the calendar year portion of the sentence, which is consistent with the regulations. • Pg. 50 lists allowable equipment and activities that may include a limited list that does not fully reflect the allowable scope of AT in the regs because it lists both types of AT and purposes of AT. Specifically, the allowable list in the manual does not reference AT that enables an individual to actively participate in other waiver services. This purpose of AT is referenced in both the regulations and in the manual on the previous page that lists what AT is supposed to enable. Furthermore, CMS guidance permits lists of allowable items to be used for administrative purposes only, but not to deny items that are not on an allowable list (reference DeSario letters). o Recommend replacing the allowable equipment and services list on page 50 about the types of allowable AT to, “Allowable equipment and activities may include specialized medical equipment and ancillary equipment; durable or nondurable medical equipment and supplies; adaptive devices, appliances, and controls; and other equipment, devices, items, and software that meets the service definition.” • Pg. 51 is a stand-alone exclusion that is neither supported by the regs nor referenced in the allowable items section of the regs or the manual, “Items such as furniture shall not be approved if they are of general utility and are not of direct medical benefit.” The regulations require an independent professional consultation that should determine on its own merit if the AT is needed to, “enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, or to participate in other waiver services. (12VAC30-122-270),” in order for the AT to be approved, making this additional stipulation unnecessary. o Recommend deletion of the entire sentence. • Pg. 51 about software compatibility is more restrictive than regulations, “AT providers must ensure that requests for software are compatible with the individual’s current computer.” This assumes all individuals have a computer at all, let alone one that is compatible with every type of software that might be evaluated as necessary AT by an independent professional’s recommendation. The regulations are clear that the independent professional shall determine the most appropriate item(s) for the individual’s needs, which may be compatible with a device that they already own or may require upgrades, enhancements, or a separate device. o Recommend deletion of the entire sentence. • Pg. 51 under Service Units and Service Limitations, first bullet, “for a specific timeframe” does not clarify the implementation of the regulation. The only timeframe specified in the regulations at (12VAC30-122-270) is the budget limit for a calendar year, and many prior authorization systems only accept a 1 month service period for the AT code used for service authorization requests. o Recommend either deleting “for a specific timeframe” or revising to, “for the timeframe specified by the service authorization system.” • Pg. 52 under Service Units and Service Limitations bullet about AT under EPSDT for children is vague, confusing, and is more restrictive than the regulation. The regulation at (12VAC30-122-270) C.4. Service units and limitations says, “Requests for AT service via a DD Waiver shall be denied if the AT service is available under EPSDT.” Nowhere in any of the regulations are children under 21 limited to only AT available under EPSDT. Instead of instructions and guidance about how to coordinate the AT benefits that children are eligible to receive under both EPSDT and HCBS in order to comply with the regulation if the requested AT is not available to the child under EPSDT, the proposed manual language only says, “AT for individuals younger than 21 years of age must be accessed through the EPSDT benefit,” indicating children may only access AT under the EPSDT benefit. o Recommend revision: “AT for individuals younger than 21 years of age may be requested via a DD Waiver if the AT is not available to the child under EPSDT.” • Pg. 52 Service Exclusions first bullet assumes all of the items listed will only ever be for the purposes of convenience, restraint, or recreational or leisure purposes. This administrative declaration circumvents and undermines the fundamental requirement for an independent, professional consultation/evaluation, and could restrict individuals from accessing the least expensive, most cost-effective manner of meeting the regulatory purpose of AT, “to enable individuals to increase abilities to perform ADLs; to perceive control, or communicate with their environment; to actively participate in other waiver services; or are necessary for the proper functioning (12VAC30-122-270)” of other equipment. As drafted, the manual permits service authorization staff to overrule the independent professional if any item related to those excluded, regardless of compliance with the regulations. Blanket exclusions are unnecessary and contradictory to the several pages of criteria, guidance, exclusions, and instructions in the manual that safeguard the AT fund for appropriate and compliant utilization. o Recommend deletion of the entire first bullet. • Pg. 53 last bullet under Service Exclusions was just copied from the regulations into the draft manual without any additional explanation or guidance. It is about duplication of payment for services that are reasonable accommodation requirements of the ADA and other Acts. What constitutes a duplication of payment? If an AT service is otherwise paid by whom? The HCBS AT budget? The Waiver? A Waiver provider? The State Plan? Another State entity? If the individual already has the AT that provides reasonable accommodation, then the independent professional would not recommend it as a needed item. Please describe a real-world example of a duplicate waiver payment for AT that supports this restriction. o Recommend revision with example that provides a better understanding of the regulation. • Pg. 54 bullet under Provider Documentation Requirements says, “Documentation in the Support Coordination record of notification by the individual or individual’s representative family/caregiver of satisfactory completion or receipt of the service or item.” This is supported in the regulations but is not a requirement that the AT provider can fulfill. o Recommend removing this bullet from the Provider Documentation Requirements and consider adding a separate Support Coordinator Requirements list and/or adding it to the Support Coordination Manual also currently open for public comment. • Pg. 54 last bullet under Provider Documentation Requirements is for the “Support Coordinator to perform and document a face-to-face visit to assure that the individual can use the AT safely and appropriately.” This is not a requirement for provider documentation and is not supported in the regulations at (12VAC30-122-270). The other documentation requirements listed in the manual are copied from the regulations without additional detail or guidance, but this particular bullet does not reflect any requirement in the regulations for a face-to-face visit or assurance of safe and appropriate use. Only a professional trained in the AT item could make an assurance that the individual can use the AT safely and appropriately, which is part of the required independent professional consultation/evaluation. o Recommend deletion of the entire sentence.   Durable Medical Equipment and Supplies Manual, IV Regulations 12VAC30-122-270 • Pg. 27, “All assistive-technology equipment must be medically necessary and essential for the treatment of illness or injury,” which contradicts the regulatory definition of AT that differentiates AT from DME where DME treats illness or injury and AT enables personal functioning, “enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, or to participate in other waiver services. (12VAC30-122-270)” AT regulations don’t require items to be medically necessary or essential, and do not require treatment of illness or injury, “to increase his ability to control his environment, support ISP outcomes as identified, and live safely and independently in the least restrictive community setting. (12VAC30-122-270)” o Suggested deletion and revision, “Assistive-technology equipment includes, but is not limited to, adaptive utensils, wall-mounted insulin delivery devices, and automatic feeder systems, and other technologies needed in any setting to increase the individual’s ability to control his environment, support ISP outcomes as identified, and live safely and independently in the least restrictive community setting. All assistive-technology equipment must be medically necessary and essential for the treatment of illness or injury.” • Pg. 27, “Assistive technology equipment does not include… items that are not for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body part…” This directly contradicts the regulatory differences between DME and AT where DME treats illness or injury, and AT enables personal functioning, “enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, or to participate in other waiver services. (12VAC30-122-270)” AT doesn’t have to diagnose or treat a condition or malformed body parts. o Suggested deletion of the phrase, “items that are not for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body part;.” • Pg. 27 includes a reference, “(12 VAC 30-50- 165)” that is irrelevant to AT. It refers to a requirement for DME to be suitable for use in the home, which directly contradicts the AT regulations that permit the use of AT in any setting, “in the individual's primary home, primary vehicle, community activity setting, or day program,” and “in the least restrictive community setting (12VAC30-122-270).” o Suggest deleting “(12 VAC 30-50- 165)”. • Pg. 27 states that AT must be approved under individual based outcomes or supportive activities to accomplish outcomes, “The following conditions must be met for DMAS to approve reimbursement of assistive technology equipment. Approval may occur under one of the following categories,” where at least one of two criteria must be met for individual-based outcomes, or all criteria must be met for supportive activities to accomplish outcomes. These stipulations are more prescriptive than and contradictory to regulations. Including these conditions in the administrative manual will permit MCOs to deny literally all AT requests. Furthermore, CMS guidance permits lists of allowable items to be used for administrative purposes only, but not to deny items that are not on an allowable list (reference DeSario letters). o Suggest deletion of, “Approval may occur under one of the following categories:” and making revisions to the “categories” as suggested below to remain compliant with the regulations at 12VAC30-122-270. • Pg. 27, “An identified, realistic goal exists that makes necessary the use of the assistive technology equipment for the treatment of the medical condition,” or “anticipated stabilization of the medical condition or progress toward goal achievement is clearly related to the use of the equipment.” Pg. 28 details the second category that AT may be approved under, “Supportive Activities to Accomplish Outcomes (all of the following must be met).” AT regulation doesn’t require the item to meet any individual outcome, treat or stabilize a medical condition, or require the individual to have a goal that is related to the use of the AT. This guidance misrepresents the regulation entirely, which already includes detailed criteria and allowable activities; service requirements; service units and limitations; provider qualifications and requirements; and service documentation and requirements. None of those detailed regulations mention medical treatment or outcomes/goals. Instead, the regulations include, the AT item will, “support ISP outcomes as identified… enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, to participate in other waiver services. (12VAC30-122-270)” • Pg. 28 criteria require that, “Goal(s) must be a part of an active, rehabilitative, therapeutic plan of care in place at the initiation of the use of the equipment. The goal(s) must be realistic in that it is consistent with the individual’s cognitive, environmental, and physical status,” but regulations do not limit items to therapeutic use or require a therapy plan. Only supporting needs identified in the support plan is referenced, “shall entail specialized equipment…, including those specified in the individual support plan.” AT requests require an independent consultation, “an independent professional consultation to determine the level of need that is not performed by the AT service provider shall be obtained from staff knowledgeable of that item for each AT service, (12VAC30-122-270),” not a plan of care. • Pg. 28 criteria require that, “the individual or caregiver demonstrates the ability cognitively, motivationally, and physically to effectively utilize the equipment toward goal achievement. Someone is available to regularly assist the individual as necessary in the use of the equipment to facilitate progress toward the goal.” None of this is supported by the regulations and none of it is enforceable. How should an AT provider demonstrate that someone has the ability to motivationally effectively use the item; what happens if a caregiver doesn’t regularly assist the individual; and who determines if progress toward a goal is made, how, and when? More importantly, why is the AT provider who delivers equipment held accountable for the performance of other services and why is a single piece of equipment solely responsible for achieving progress? • Pg. 28 criteria require, “within the plan of care, documentation exists that other equipment and/or health care alternatives have been considered and rejected as not appropriate for the treatment of the medical condition.” AT regulations do not require other equipment or alternatives to have failed to treat a medical condition before the AT request will be considered. Other equipment is only noted if a rehabilitation engineer is requested, “if an existing device must be modified or a specialized device must be designed and fabricated, a rehabilitation engineer or certified rehabilitation specialist may be utilized. (12VAC30-122-270)” • Pg. 28 criteria exclude an individual’s eligibility for AT if they have a low energy condition, “the individual does not have a deficient level of “energy” or other systemic condition (e.g., CHF, COPD).” Anyone who has these or other chronic diagnoses that cause low energy levels could be denied for all AT requests. Regulations require an independent consultation to ensure the individual is capable of using the item. An additional administrative criteria is unnecessary and potentially discriminatory. • Pg. 28 requires, “the equipment must reduce the need for other reimbursed health care (such as personal care, private duty nursing, rehabilitation services, and/or home health services).” This is entirely contradictory to the regulation and not supported anywhere. Suggested Revisions for the section that begins with, “The following conditions,” through the end of the AT section on p28 to comply with AT regulations (12VAC30-122-270): “The following conditions must be met for DMAS to approve reimbursement of assistive technology equipment. These conditions are applicable whether the equipment is for initial use or replacement. Individual use of the requested AT will enable increased abilities to: (at least one) 1. Perform activities of daily living (ADLs); 2. Perceive, control, or communicate with their environment; 3. Actively participate in other waiver services that are part of their plan for supports; 4. Be independent in areas of personal care; 5. Communicate more effectively; 6. Support of individual service plan outcomes as identified; or 7. Properly use items necessary for life support, including the ancillary supplies and equipment. For each assistive technology request for approval, the AT provider or the independent professional shall provide documentation of: • Recommendation for the requested AT based on a consultation not performed by the AT service provider, but rather an independent professional knowledgeable of both the requested AT and the individual’s needs that it will address. • Applicable standards of manufacture, design, and installation, and the provider will provide all warranties or guarantees from the AT manufacturer to the individual and family/caregiver, as appropriate. • If the AT will be initiated in combination with environmental modifications involving systems that are not compatible, or an existing device must be modified or a specialized device must be designed and fabricated, a rehabilitation engineer or certified rehabilitation specialist may be utilized. • Not solely for purposes of convenience of the caregiver, restraint of the individual, or recreation or leisure activities. • Not otherwise available through the State Plan for Medical Assistance. • Used in the least restrictive community setting, which includes the individual's home, vehicle, community activity setting, or day program. In order for an AT claim to be reimbursed, all of the following must be documented: • Prior authorization received before delivery • AT was received or installed and in working order • Warranties and procedures for technical support were provided • Individual is capable of using AT”

• People with a BI waiver need access to therapeutic consultation, “professional consultation to assist individuals, parents, guardians, family members, and any other providers of support services with implementing the ISP.” This service provides expert consultation to the entire support system that enables them to achieve outcomes in the ISP without the expense of ongoing therapy services. o DMAS is aware of significant and systemic barriers to accessing technology that individuals need to interact with their providers and greater community. TC providers are specifically and uniquely qualified to provide assistive technology and medical equipment assessments, recommendations, training, and follow-up adaptations in accordance with the manual and the regulations, “provides assessments, development of a therapeutic consultation support plan, and teaching in any of these designated specialty areas to assist family members, caregivers, and other providers in supporting the individual.” Increasing access to TC to more people for AT assessment and facilitation would alleviate these barriers for individuals who don’t know how to engage and participate in the virtual environment, including telemedicine with healthcare providers. o TC offers an opportunity for provider choice from multiple disciplines and is one of the few regulated and reimbursable services that can be delivered effectively from a safe distance via telehealth and telephonic consultation. Individuals and families want more control over the services they receive and how they receive them. Access to consultation with an expert in any discipline of therapy would demonstrate to advocates Virginia’s commitment to the principles of the DOJ settlement, which includes all HCBS waiver recipients. o All individuals, regardless of which waiver they have, is experiencing the detrimental impacts of uncontrollable environmental changes throughout our community, including support provider shortages, limited choice and control of care setting and service duration, and lack of workforce modernization resources for service providers. Individuals with a BI waiver are experiencing equally disruptive changes to the capabilities of their support system to implement their ISP as those with the FIS and CL waivers. • Pg. 142, “consultation provided by members of … disciplines that are designed to assist… with implementing the ISP,” mirrors the regulation at 12VAC30-122-550. However, because assistive technology professionals (ATPs) are not listed in the examples of disciplines that can provide TC, DMAS will not enroll them as providers. This is a wasted opportunity. The Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) provides standardized credentialing for an ATP Certification, “The ATP certification recognizes demonstrated competence in analysing the needs of consumers with disabilities, assisting in the selection of appropriate assistive technology for the consumers' needs, and providing training in the use of the selected devices.” The TC manual and regulation provide allowable activities examples that include, “Assessing the individual's need for an assistive device for a modification or adjustment of an assistive device, or both, in the environment or service, including reviewing documentation and evaluating the efficacy of assistive devices and interventions identified in the therapeutic consultation plan.” The ATP discipline meets the regulatory requirement as a discipline, “designed to assist with implementing the ISP 12VAC30-122-550.” o Suggest adding “Assistive Technology Professional” to the list of example disciplines appropriate to provide TC services.

COMMENTS ON ELECTRONIC HOME BASED SUPPORTS (EHBS) IN THE DD WAIVER MANUAL CHAPTER IV PG. 61 DD Manual, IV pg. 61 Only one unit of service is only appropriate for equipment or items that are delivered once. Services that include ongoing monitoring and other supports delivered electronically occur periodically and routinely as needed by the individual, similar to therapeutic consultation. Please consider separating administration of EHBS coverage of equipment from EHBS coverage of services to allow for appropriate and compliant service authorization and billing for ongoing services.

DD Waiver Manual - Chapter 6 - 30-Day Public Comment - vaACCSES

Quality Management and Utilization Reviews

Introduction
Page 1:

• First paragraph, 2^nd sentence - who is DMAS’s “designated agent”? Recommend clarification between DMAS QMR staff and any subcontracted contractor for financial audits, etc.
• First paragraph, 4^th sentence states “DMAS conducts compliance reviews on providers that are found to provide services in excess of established norms, ..."
  Comment:  Shouldn't this be just on those that do not provide services in accordance with the regulations?  What does "established norms" mean? Language needs to be changed or definition of “established norms” needs to be provided.

General Requirements
Page 1:

• Second paragraph, 1st sentence states "DMAS participation standards and policies".
  Comment:  Shouldn’t this refer to regulations as in the following sentence?  If “standards and policies” is retained - definition or citation needs to be included.

Page 2:

• 1^st sentence - general grammar problem - comma needed following the word "individuals”.
• Second paragraph, 1st sentence - Who is "staff"?  We assume “DMAS QMR staff” in this instance.
  Comment:  Helpful to state and delineate between DMAS QMR staff and provider staff within this paragraph and others to provide clarity. Also, "staff may request licenses” - However, not all providers are required to have staff that is licensed. Add “providers and staff required to have licenses”.  Differentiate between requirements of services that are licensed and services that are not licensed regarding criminal background checks and what “documentation” is required.

• Third paragraph, 2nd sentence - Again, the requirement to be in compliance with "DMAS provider agreements and policies"
  Comment:  Shouldn’t this refer to regulations?  If “standards and policies” is retained - definition or citation needs to be included for clarity.

• Fourth paragraph, 3rd sentence - Use of the word "provider" here. 
  Comment:  Assume this means the Agency Provider and not the Personal Care provider. However, “provider” is used interchangeably for both throughout document. “Staff” is also used interchangeably throughout the document. Clarity and specificity is needed consistently.

Page 3:

• Bullet 1, 1st sentence - states "within the program's guidelines"?  Should this be "in accordance with regulations"?
• Bullet 1, 2nd sentence - Same comment as above related to the use of the word "provider".
• Bullet 1, 3rd sentence -
  Comment:  What is considered to be "the individual's record"?  Add specific reference to what record.  Is it enough to document these things in a provider’s system?  Also, what is classified as "any substantial change"?  And what specific "documentation of such change" is required? Please add specificity.
• Bullet 1, 4th sentence - Recognize that provider’s responsibility to identify “substantial changes” and inform the Support Coordinator. 
  Comment:  However, it is the Support Coordinator’s role to obtain and coordinate those services that the individual requires to remain in the community and not the provider. The "or" that follows that requirement should be replaced with "so that the Support Coordinator can obtain any other services,...."
• Bullet 3, 2nd sentence - Clarity needed.
  Comment:  Who is considered "provider staff"?  and who is the "provider agency representative"?  In the case of Service Facilitation - clarity is needed since the SF is the one both in communication with the individual AND the one responsible for the oversight of the plan.
• Manual Pg 3, bullet 3, last sentence à where should the "providers" find the remaining list of quality of supports if this is just "some" of them?  Remember, not every provider is licensed, so we are only following the regulations and this handbook.
• Manual Pg 3, bullet 4 à are we allowed to use electronic signature now?  Where did that change in the regulations?

Page 4:

• Bullet 1 - Use of "provider" again and "maintain a record"? 
  Comment:  Can that be just be in the provider’s system?  It's confusing since the next sentence mentions the forms.  So is the "record" the "form"?  Are those one and the same?  Why not use the same word for both spots?
• 1st full paragraph - "DMAS will review the provider's performance in all the outcome areas to determine the provider's ability to achieve high quality supports..." 
  Comment:  This is where that word "provider" gets used interchangeably again.  The SF writes outcomes based on the Part 3, but the outcomes are for the Personal Care Attendant to provide to the individual and not for the SF to provide to the individual.  So, who is the "provider" whose performance DMAS is reviewing? Further clarification is needed.
• General Comment on consistency - The language is now referring to DMAS.  "DMAS will review", "DMAS will evaluate", "DMAS may require".  Before, in this same document, it refers to "staff".  Consistency is needed throughout.
• 2nd full paragraph - Shouldn’t the regulations be mentioned here instead of “policies and procedures”?
• Bullet 1 - Further clarity is needed.  What exactly is meant by "periodically"?
• Bullet 5, sentence 1  - A sentence is needed to differentiate Service Facilitation and CD services from other services and their specific requirements. States "Staff" will meet with at least one individual or PCG to determine satisfaction with the provider.  Which provider is that?  The SF provider agency?  Or the PCA provider?  Not clear regarding what would be measured for SF. 

Page 5:

• Bullet 1 - why is "provider" underlined?  Who is "staff"?  Appreciate the reference to regulations vs “policies and procedures”.   
• Bullet 3  - Who is submitting this letter to these other agencies? Specificity needed.

Comprehensive and Ongoing Assessment and Planning

Page 8:  Bullet 1, sub-bullet 5 - A parenthesis is missing here.

Page 10: Bullet 3 - Why is "the waiver enrollment date" underlined?

Services are Delivered, Reviewed and Modified as Needed
Page 11:   
Comment:  Is this for all providers or specific to Case Management?  The first bullet/sub-bullet seems to speak to each service provider, but then the second sub-bullet is specific to Case Management.  Then the third sub-bullet goes back to "each service provider".  Recommend to separate and list bullets under either provider and case management for clarity

Page 12:  Main Bullet
Comment:  Sub-bullet 1 - Provide specificity in Manual. What DMAS form is to be used for the quarterly review?  There is currently no consistency from CSB to CSB on what documentation is required to be used for quarterlies.  There is also no consistency as to what has to be in that quarterly review.  Specificity would be helpful to provide consistency.

Page 13: 

• 1st sub-bullet à "All providers must be invited to the meeting and participate in the development of the new ISP annually."  Are SF required to be present at the meeting?  Service Facilitators are not compensated for this meeting and can only bill for a reassessment visit. These meetings can be up to 3+ hours.

Services Delivered are Consistent With Service Limits
Page 13:  Bullet 1, sub-bullet 2 -
Comment:  Need additional specificity for Service Facilitation - recommend separate sub-bullet. "The number of hours does require authorization."  What hours?  MT Units?  PCA hours?  Respite Hours?  Companion Hours?  The hours the SF is working?

Page 15: Bullet 2
Comment:  Paper timesheets went away a long time ago, so the EOR and employee will not be signing them.  Time is either logged via app, online portal, or by calling in using IVR.  So billing for CD services will not be supported by a timesheet that is signed.  This point in the manual needs to be removed.

Support Coordinator/Case Manager/Provider Responsibilities
Page 23:
Comment:  Need to REMOVE “Provider” from this section. “Provider” should not be included in this title when the first paragraph says that the following things are the responsibility of the support coordinator/case manager, and doesn't mention the provider?  None of the things listed are the responsibility of the provider.

DD Waiver Manual - Chapter 4 - Part 1 of 2
30-Day Public Comment - vaACCSES

GENERAL COMMENTS:

1. Purpose of Manual to provide explanation, clarification, definition, examples, possible service scenarios, and interpretation for providers to deliver consistent implementation of quality services, documentation and required reports across the Commonwealth. However, we have found that there are numerous items in the Manual that are more prescriptive than what is included within DD Waiver regulatory authority - which is problematic. The Manual should not be more prescriptive than regulations since the governing authority are the regs. The addition of regulatory citations would help as reference throughout the Manual as appropriate. 
2. Consistency between Regulations and Manual is critical.  There are multiple examples throughout the Manual of inconsistencies between licensing regulations, DD Waiver regulations and what’s required by DMAS in the Provider Agreement.  All of this makes it confusing for the provider and creates additional administrative burden.  It also complicates the rules for providers that provide “unlicensed services”.  Because the service is unlicensed, it makes it difficult to know and fulfill requirements that refer to the licensing regulations and/or to forms referenced.
3. Chart with “Corresponding Regulations” and BI, FI and CL columns are a helpful visual and provide clarity regarding regulation reference at the beginning of each service.  We recommend that a chart be used for all services in Chapter 4. (See page 78 as example).
4. There is an overall need to clearly delineate the responsibilities and requirements for support coordinator actions versus service provider actions.  Ideally, support coordination would either have a companion Manual or minimally, within the Waiver manual, have clear sections within chapters and/or services. Possibly, even a separate chapter with ONLY the Support Coordination requirements and responsibilities. The lack of separation and specificity are confusing regarding responsibility and requirements of “providers” throughout the Manual.  The question asked often throughout is “which provider is responsible”.
5. We request that overall instructions on how providers should round any fractions of service hours provided for billing purposes. This is not included in the current Manual but would be very helpful as an overall instruction to provide specification and consistency. In the past when we asked, we were told that these instructions were to be included in the future Manual in a chapter for “other services”.  It would of course be efficient to include this information within the Waiver manual.

CHAPTER 4:

Table of Contents & Service Option Charts:
Corrections Needed:

• Individual & Family/Caregiver Training is incorrectly marked as included in the BI waiver - should be FIS Waiver
• Workplace Assistance Services is incorrectly marked as only being included in the FIS Waiver - it is also included in the CL Waiver.

Page 1 - Criteria to Be Eligible -
Comment:  What if they do not have "functional limitations in major life activities" - but might need Companion Care or Sensory Equipment (AT or DME)?

Diagnostic Eligibility

Page 2, paragraph 1:
COMMENT:  Correction Needed. Paragraph refers to “three of more criteria described in (1) through (5) above…”  Please change bullets to numbers for clarity.

Day Assessment Service Authorization Requests

Page 22:

Comment:  Would prefer that the language used provide additional clarity than the 60-day assessment is an option (“may”) - but not required. Recommend - “Provider has the option to request a 60-day assessment prior to initiating plan for supports.”

Page 23:  Provider Discontinuation of Services.

Comment: Regarding 10 business days advanced notice in writing. This is not always possible. Individual Supported Employment (ISE) services, for example, will end when an individual quits or is terminated from a position and DARS categories are open. Would prefer language that better reflects that this is best practice when possible but not required. Additionally, it indicates that in a situation in which health/safety concerns are the reason for discharge, DBHDS must be notified – who at DBHDS is to be notified?

Assistive Technology (AT)  

General Comment: Assistive Technology (AT) is an HCBS waiver benefit that all recipients of DD waivers and CCC+ waivers are equally entitled to access in accordance with regulations at 12VAC30-122-270. Although there is only one regulation for AT, guidance for administration of it is inconsistent. AT requests for people with a DD waiver are approved by DBHDS according to the DD Waiver Manual Chapter IV and AT requests for people with the CCC+ waiver are approved by the MCO or KePRO according to the Durable Medical Equipment (DME) and Supplies Manual Chapter IV. Review of both manuals find extensive differences and variations, and both manuals are more restrictive than the AT regulations they are purported to clarify.

These contradictions and inconsistencies represent the root causes of many of the barriers that individuals, providers, and DMAS are experiencing as reported by the HB2197 working group that DMAS was charged with hosting to identify barriers to accessing AT and related services as well as options for removing them. Making the administrative manual changes recommended below will remove many of these barriers that impact over 30,000 people with disabilities. Only the DD Waiver Manual is open for public comment; the DME Manual was closed in June 2021 after receiving zero comments. We strongly urge DMAS to revise both Manuals to appropriately reflect the AT regulations at 12VAC30-122-270. Suggested revisions for both manuals are provided below.

Relevant Regs at 12VAC30-122-270.

Page 49 - Service Description - 2^nd to last sentence
Comment:  “Assistive technology devices are portable and authorized per calendar year” is inconsistent with the regulations, which do not require AT devices to be portable. Recommend DELETE “are portable and” to retain the calendar year portion of the sentence, which is consistent with the regulations.

Page 50 - Examples - Allowable Equipment Table

Comment:  Lists allowable equipment and activities that may include a limited list that does not fully reflect the allowable scope of AT in the regs because it lists both types of AT and purposes of AT. Specifically, the allowable list in the manual does not reference AT that enables an individual to actively participate in other waiver services. This purpose of AT is referenced in both the regulations and in the manual on the previous page that lists what AT is supposed to enable.

Recommend replacing the allowable equipment and services list on page 50 about the types of allowable AT to, “Allowable equipment and activities may include specialized medical equipment and ancillary equipment; durable or nondurable medical equipment and supplies; adaptive devices, appliances, and controls; and other equipment, devices, items, and software that meets the service definition.”

Page 51

Comment: This is a stand-alone exclusion that is neither supported by the regs nor referenced in the allowable items section of the regs or the manual, “Items such as furniture shall not be approved if they are of general utility and are not of direct medical benefit.” The regulations require an independent professional consultation that should determine on its own merit if the AT is needed to, “enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, or to participate in other waiver services. (12VAC30-122-270),” in order for the AT to be approved, making this additional stipulation unnecessary.

Recommend deletion of the entire sentence.

Page 51 -
Comment:  Sentence about software compatibility is more restrictive than regulations, “AT providers must ensure that requests for software are compatible with the individual’s current computer.” This assumes all individuals have a computer at all, let alone one that is compatible with every type of software that might be evaluated as necessary AT by an independent professional’s recommendation. The regulations are clear that the independent professional shall determine the most appropriate item(s) for the individual’s needs, which may be compatible with a device that they already own or may require upgrades, enhancements, or a separate device.

Recommend deletion of the entire sentence.

Page 51 - Service Units and Service Limitations - 1^st Bullet
Comment: “for a specific timeframe” does not clarify the implementation of the regulation. The only timeframe specified in the regulations at (12VAC30-122-270) is the budget limit for a calendar year, and many prior authorization systems only accept a 1-month service period for the AT code used for service authorization requests.

Recommend either deleting “for a specific timeframe” or revising to, “for the timeframe specified by the service authorization system.”

Page 52 - Service Units and Service Limitations Bullet about AT

Comment: under EPSDT for children is vague, confusing, and is more restrictive than the regulation. The regulation at (12VAC30-122-270) C.4. Service units and limitations says, “Requests for AT service via a DD Waiver shall be denied if the AT service is available under EPSDT.” Nowhere in any of the regulations are children under 21 limited to only AT available under EPSDT. Instead of instructions and guidance about how to coordinate the AT benefits that children are eligible to receive under both EPSDT and HCBS in order to comply with the regulation if the requested AT is not available to the child under EPSDT, the proposed manual language only says, “AT for individuals younger than 21 years of age must be accessed through the EPSDT benefit,” indicating children may only access AT under the EPSDT benefit.

Recommend revision: “AT for individuals younger than 21 years of age may be requested via a DD Waiver if the AT is not available to the child under EPSDT.”

Page 52 - Service Exclusions - 1^st Bullet
Comment:  Assumes all of the items listed will only ever be for the purposes of convenience, restraint, or recreational or leisure purposes. This administrative declaration circumvents and undermines the fundamental requirement for an independent, professional consultation/evaluation, and could restrict individuals from accessing the least expensive, most cost-effective manner of meeting the regulatory purpose of AT, “to enable individuals to increase abilities to perform ADLs; to perceive control, or communicate with their environment; to actively participate in other waiver services; or are necessary for the proper functioning (12VAC30-122-270)” of other equipment. As drafted, the manual permits service authorization staff to overrule the independent professional if any item related to those excluded, regardless of compliance with the regulations. Blanket exclusions are unnecessary and contradictory to the several pages of criteria, guidance, exclusions, and instructions in the manual that safeguard the AT fund for appropriate and compliant utilization.

Recommend deletion of the entire first bullet.

Page 53 - Last Bullet - Service Exclusions
Comment:  Same as regulation. Additional explanation or guidance would be appreciative. It is about duplication of payment for services that are reasonable accommodation requirements of the ADA and other Acts. What constitutes a duplication of payment? If an AT service is otherwise paid by whom? The HCBS AT budget? The Waiver? A Waiver provider? The State Plan? Another State entity? If the individual already has the AT that provides reasonable accommodation, then the independent professional would not recommend it as a needed item. Please describe a real-world example of a duplicate waiver payment for AT that supports this restriction.

Recommend revision with example that provides a better understanding of the regulation.

Page. 54 - Provider Documentation Requirements
Comment: states “Documentation in the Support Coordination record of notification by the individual or individual’s representative family/caregiver of satisfactory completion or receipt of the service or item.” This is supported in the regulations but is not a requirement that the AT provider can fulfill.

Recommend removing this bullet from the Provider Documentation Requirements and consider adding a separate Support Coordinator Requirements list and/or adding it to the Support Coordination Manual also currently open for public comment.

Page 54 Provider Documentation Requirements - Last Bullet -
Comment:  States for the “Support Coordinator to perform and document a face-to-face visit to assure that the individual can use the AT safely and appropriately.” Overly burdensome. This is not a requirement for provider documentation and is not supported in the regulations at (12VAC30-122-270). The other documentation requirements listed in the manual are copied from the regulations without additional detail or guidance, but this particular bullet does not reflect any requirement in the regulations for a face-to-face visit or assurance of safe and appropriate use. Only a professional trained in the AT item could make an assurance that the individual can use the AT safely and appropriately, which is part of the required independent professional consultation/evaluation.

Recommend deletion of the entire sentence.

Community Guide Services

Page 59 - 3rs Bullet - Documentation Requirements
Comment: States “Observations of the individual’s responses to the service must be available in at least a daily note”. Community Guide services are not necessarily provided on a daily basis.  Is this needed and realistic. Recommend deleting “daily” from note.

Electronic Home-Based Supports (EHBS)

General Comment:  The regs and the manual are aligned with one another in a way that only makes sense for equipment. In order for providers to deliver services under EHBS, the unit of service cannot be limited to only one.
Recommend Additional Language Be Added: "Only one unit of service is only appropriate for equipment or items that are delivered once. Services that include ongoing monitoring and other supports delivered electronically occur periodically and routinely as needed by the individual, similar to therapeutic consultation. Please consider separating administration of EHBS coverage of equipment from EHBS coverage of services to allow for appropriate and compliant service authorization and billing for ongoing services."

Page 63 - Service Documentation Requirements - Bullet #2
Comment:  This documentation is the requirement of the Support Coordinator and not the EHBS provider.

Individual and Family Caregiver Training

Page 70:
Indicates that contact notes, monthly notes, and quarterly reports must be completed. This is more than the regulations require.  Is also duplicative. It is also more information than is required for other services.  Other services require a quarterly review. Clarification is needed if monthly summaries are needed when there is a quarterly review being completed.

Transition Services

Page 74 Paragraph 1 and Page 75 Last Paragraph - Inconsistent language
Comment:  Page 74 includes language that an “individual has 30 days after transitioning to apply for Transition Services”.  Page 75 states that “service authorization must be obtained within 30 days of discharge.  Recommend clarification and consistent language be used to avoid confusion.

Benefits Planning
Page 90: Criteria/Allowable Activities
1^st Paragraph
Comment:  DELETE “or” before “employment status” and ADD “or need for work incentives”.

Page 94:
Paragraph 1:  Indicates that this service requires face to face contact.
Comment:  Regulations do not specify that this be a face-to-face contact.  Alternative options must be available including telehealth and virtual options. Overly prescriptive and not included in regulations.

Page 95: Mid-page - Bullet 1 -
Comment:  ADD “or is not available” after “have been explored and exhausted”.  Also, please clarify what documentation is needed to fulfill the requirement of “explored or exhausted”.

Page 95: Mid-page - Bullet 2 - Indicates there should be documentation of “All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS”
Comment:  Should also include “DSS and SSA as appropriate” for this particular service.

Community Engagement

Page 102 - Criteria/Allowable Activities
Paragraph 1 - Last Sentence
Comment:  Underlined sentence is confusing.  Should “community engagement” be substituted for “supported employment”?

Page 104 - 7^th Bullet:
Comment:  ADD “independent” before “living skills”

Group Day Services

Page 112 - Service Definition/Description
1^st Paragraph - Last Sentence:  DELETE “these services”.

Page 114:  Semi-Predictable Events
Paragraph 1:  States “The provider may request between 3-5 hours of additional “community engagement” per week that will allow the individual to choose additional community outings.
Comment:   Shouldn’t this read:  “The provider may request between 3-5 hours of additional “group day” services per week that will allow the individual to choose additional “group day” activities.  It is not clear.  If Community Engagement - then it should be included in the Community Engagement service section.

1. Purpose of Manual to provide explanation, clarification, definition, examples, possible service scenarios, and interpretation for providers to deliver consistent implementation of quality services, documentation and required reports across the Commonwealth. However, we have found that there are numerous items in the Manual that are more prescriptive than what is included within DD Waiver regulatory authority - which is problematic. The Manual should not be more prescriptive than regulations since the governing authority are the regs. The addition of regulatory citations would help as reference throughout the Manual as appropriate. 
2. Consistency between Regulations and Manual is critical.  There are multiple examples throughout the Manual of inconsistencies between licensing regulations, DD Waiver regulations and what’s required by DMAS in the Provider Agreement.  All of this makes it confusing for the provider and creates additional administrative burden.  It also complicates the rules for providers that provide “unlicensed services”.  Because the service is unlicensed, it makes it difficult to know and fulfill requirements that refer to the licensing regulations and/or to forms referenced.
3. Chart with “Corresponding Regulations” and BI, FI and CL columns are a helpful visual and provide clarity regarding regulation reference at the beginning of each service.  We recommend that a chart be used for all services in Chapter 4. (See page 78 as example).
4. There is an overall need to clearly delineate the responsibilities and requirements for support coordinator actions versus service provider actions.  Ideally, support coordination would either have a companion Manual or minimally, within the Waiver manual, have clear sections within chapters and/or services. Possibly, even a separate chapter with ONLY the Support Coordination requirements and responsibilities. The lack of separation and specificity are confusing regarding responsibility and requirements of “providers” throughout the Manual.  The question asked often throughout is “which provider is responsible”.
5. We request that overall instructions on how providers should round any fractions of service hours provided for billing purposes. This is not included in the current Manual but would be very helpful as an overall instruction to provide specification and consistency. In the past when we asked, we were told that these instructions were to be included in the future Manual in a chapter for “other services”.  It would of course be efficient to include this information within the Waiver manual.

CHAPTER 4:

Table of Contents & Service Option Charts:
Corrections Needed:

• Individual & Family/Caregiver Training is incorrectly marked as included in the BI waiver - should be FIS Waiver
• Workplace Assistance Services is incorrectly marked as only being included in the FIS Waiver - it is also included in the CL Waiver.

Page 1 - Criteria to Be Eligible -
Comment:  What if they do not have "functional limitations in major life activities" - but might need Companion Care or Sensory Equipment (AT or DME)?

Diagnostic Eligibility

Page 2, paragraph 1:
COMMENT:  Correction Needed. Paragraph refers to “three of more criteria described in (1) through (5) above…”  Please change bullets to numbers for clarity.

Day Assessment Service Authorization Requests

Page 22:

Comment:  Would prefer that the language used provide additional clarity than the 60-day assessment is an option (“may”) - but not required. Recommend - “Provider has the option to request a 60-day assessment prior to initiating plan for supports.”

Page 23:  Provider Discontinuation of Services.

Comment: Regarding 10 business days advanced notice in writing. This is not always possible. Individual Supported Employment (ISE) services, for example, will end when an individual quits or is terminated from a position and DARS categories are open. Would prefer language that better reflects that this is best practice when possible but not required. Additionally, it indicates that in a situation in which health/safety concerns are the reason for discharge, DBHDS must be notified – who at DBHDS is to be notified?

Assistive Technology (AT)  

General Comment: Assistive Technology (AT) is an HCBS waiver benefit that all recipients of DD waivers and CCC+ waivers are equally entitled to access in accordance with regulations at 12VAC30-122-270. Although there is only one regulation for AT, guidance for administration of it is inconsistent. AT requests for people with a DD waiver are approved by DBHDS according to the DD Waiver Manual Chapter IV and AT requests for people with the CCC+ waiver are approved by the MCO or KePRO according to the Durable Medical Equipment (DME) and Supplies Manual Chapter IV. Review of both manuals find extensive differences and variations, and both manuals are more restrictive than the AT regulations they are purported to clarify.

These contradictions and inconsistencies represent the root causes of many of the barriers that individuals, providers, and DMAS are experiencing as reported by the HB2197 working group that DMAS was charged with hosting to identify barriers to accessing AT and related services as well as options for removing them. Making the administrative manual changes recommended below will remove many of these barriers that impact over 30,000 people with disabilities. Only the DD Waiver Manual is open for public comment; the DME Manual was closed in June 2021 after receiving zero comments. We strongly urge DMAS to revise both Manuals to appropriately reflect the AT regulations at 12VAC30-122-270. Suggested revisions for both manuals are provided below.

Relevant Regs at 12VAC30-122-270.

Page 49 - Service Description - 2^nd to last sentence
Comment:  “Assistive technology devices are portable and authorized per calendar year” is inconsistent with the regulations, which do not require AT devices to be portable. Recommend DELETE “are portable and” to retain the calendar year portion of the sentence, which is consistent with the regulations.

Page 50 - Examples - Allowable Equipment Table

Comment:  Lists allowable equipment and activities that may include a limited list that does not fully reflect the allowable scope of AT in the regs because it lists both types of AT and purposes of AT. Specifically, the allowable list in the manual does not reference AT that enables an individual to actively participate in other waiver services. This purpose of AT is referenced in both the regulations and in the manual on the previous page that lists what AT is supposed to enable.

Recommend replacing the allowable equipment and services list on page 50 about the types of allowable AT to, “Allowable equipment and activities may include specialized medical equipment and ancillary equipment; durable or nondurable medical equipment and supplies; adaptive devices, appliances, and controls; and other equipment, devices, items, and software that meets the service definition.”

Page 51

Comment: This is a stand-alone exclusion that is neither supported by the regs nor referenced in the allowable items section of the regs or the manual, “Items such as furniture shall not be approved if they are of general utility and are not of direct medical benefit.” The regulations require an independent professional consultation that should determine on its own merit if the AT is needed to, “enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, or to participate in other waiver services. (12VAC30-122-270),” in order for the AT to be approved, making this additional stipulation unnecessary.

Recommend deletion of the entire sentence.

Page 51 -
Comment:  Sentence about software compatibility is more restrictive than regulations, “AT providers must ensure that requests for software are compatible with the individual’s current computer.” This assumes all individuals have a computer at all, let alone one that is compatible with every type of software that might be evaluated as necessary AT by an independent professional’s recommendation. The regulations are clear that the independent professional shall determine the most appropriate item(s) for the individual’s needs, which may be compatible with a device that they already own or may require upgrades, enhancements, or a separate device.

Recommend deletion of the entire sentence.

Page 51 - Service Units and Service Limitations - 1^st Bullet
Comment: “for a specific timeframe” does not clarify the implementation of the regulation. The only timeframe specified in the regulations at (12VAC30-122-270) is the budget limit for a calendar year, and many prior authorization systems only accept a 1-month service period for the AT code used for service authorization requests.

Recommend either deleting “for a specific timeframe” or revising to, “for the timeframe specified by the service authorization system.”

Page 52 - Service Units and Service Limitations Bullet about AT

Comment: under EPSDT for children is vague, confusing, and is more restrictive than the regulation. The regulation at (12VAC30-122-270) C.4. Service units and limitations says, “Requests for AT service via a DD Waiver shall be denied if the AT service is available under EPSDT.” Nowhere in any of the regulations are children under 21 limited to only AT available under EPSDT. Instead of instructions and guidance about how to coordinate the AT benefits that children are eligible to receive under both EPSDT and HCBS in order to comply with the regulation if the requested AT is not available to the child under EPSDT, the proposed manual language only says, “AT for individuals younger than 21 years of age must be accessed through the EPSDT benefit,” indicating children may only access AT under the EPSDT benefit.

Recommend revision: “AT for individuals younger than 21 years of age may be requested via a DD Waiver if the AT is not available to the child under EPSDT.”

Page 52 - Service Exclusions - 1^st Bullet
Comment:  Assumes all of the items listed will only ever be for the purposes of convenience, restraint, or recreational or leisure purposes. This administrative declaration circumvents and undermines the fundamental requirement for an independent, professional consultation/evaluation, and could restrict individuals from accessing the least expensive, most cost-effective manner of meeting the regulatory purpose of AT, “to enable individuals to increase abilities to perform ADLs; to perceive control, or communicate with their environment; to actively participate in other waiver services; or are necessary for the proper functioning (12VAC30-122-270)” of other equipment. As drafted, the manual permits service authorization staff to overrule the independent professional if any item related to those excluded, regardless of compliance with the regulations. Blanket exclusions are unnecessary and contradictory to the several pages of criteria, guidance, exclusions, and instructions in the manual that safeguard the AT fund for appropriate and compliant utilization.

Recommend deletion of the entire first bullet.

Page 53 - Last Bullet - Service Exclusions
Comment:  Same as regulation. Additional explanation or guidance would be appreciative. It is about duplication of payment for services that are reasonable accommodation requirements of the ADA and other Acts. What constitutes a duplication of payment? If an AT service is otherwise paid by whom? The HCBS AT budget? The Waiver? A Waiver provider? The State Plan? Another State entity? If the individual already has the AT that provides reasonable accommodation, then the independent professional would not recommend it as a needed item. Please describe a real-world example of a duplicate waiver payment for AT that supports this restriction.

Recommend revision with example that provides a better understanding of the regulation.

Page. 54 - Provider Documentation Requirements
Comment: states “Documentation in the Support Coordination record of notification by the individual or individual’s representative family/caregiver of satisfactory completion or receipt of the service or item.” This is supported in the regulations but is not a requirement that the AT provider can fulfill.

Recommend removing this bullet from the Provider Documentation Requirements and consider adding a separate Support Coordinator Requirements list and/or adding it to the Support Coordination Manual also currently open for public comment.

Page 54 Provider Documentation Requirements - Last Bullet -
Comment:  States for the “Support Coordinator to perform and document a face-to-face visit to assure that the individual can use the AT safely and appropriately.” Overly burdensome. This is not a requirement for provider documentation and is not supported in the regulations at (12VAC30-122-270). The other documentation requirements listed in the manual are copied from the regulations without additional detail or guidance, but this particular bullet does not reflect any requirement in the regulations for a face-to-face visit or assurance of safe and appropriate use. Only a professional trained in the AT item could make an assurance that the individual can use the AT safely and appropriately, which is part of the required independent professional consultation/evaluation.

Recommend deletion of the entire sentence.

Community Guide Services

Page 59 - 3rs Bullet - Documentation Requirements
Comment: States “Observations of the individual’s responses to the service must be available in at least a daily note”. Community Guide services are not necessarily provided on a daily basis.  Is this needed and realistic. Recommend deleting “daily” from note.

Electronic Home-Based Supports (EHBS)

General Comment:  The regs and the manual are aligned with one another in a way that only makes sense for equipment. In order for providers to deliver services under EHBS, the unit of service cannot be limited to only one.
Recommend Additional Language Be Added: "Only one unit of service is only appropriate for equipment or items that are delivered once. Services that include ongoing monitoring and other supports delivered electronically occur periodically and routinely as needed by the individual, similar to therapeutic consultation. Please consider separating administration of EHBS coverage of equipment from EHBS coverage of services to allow for appropriate and compliant service authorization and billing for ongoing services."

Page 63 - Service Documentation Requirements - Bullet #2
Comment:  This documentation is the requirement of the Support Coordinator and not the EHBS provider.

Individual and Family Caregiver Training

Page 70:
Indicates that contact notes, monthly notes, and quarterly reports must be completed. This is more than the regulations require.  Is also duplicative. It is also more information than is required for other services.  Other services require a quarterly review. Clarification is needed if monthly summaries are needed when there is a quarterly review being completed.

Transition Services

Page 74 Paragraph 1 and Page 75 Last Paragraph - Inconsistent language
Comment:  Page 74 includes language that an “individual has 30 days after transitioning to apply for Transition Services”.  Page 75 states that “service authorization must be obtained within 30 days of discharge.  Recommend clarification and consistent language be used to avoid confusion.

Benefits Planning
Page 90: Criteria/Allowable Activities
1^st Paragraph
Comment:  DELETE “or” before “employment status” and ADD “or need for work incentives”.

Page 94:
Paragraph 1:  Indicates that this service requires face to face contact.
Comment:  Regulations do not specify that this be a face-to-face contact.  Alternative options must be available including telehealth and virtual options. Overly prescriptive and not included in regulations.

Page 95: Mid-page - Bullet 1 -
Comment:  ADD “or is not available” after “have been explored and exhausted”.  Also, please clarify what documentation is needed to fulfill the requirement of “explored or exhausted”.

Page 95: Mid-page - Bullet 2 - Indicates there should be documentation of “All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS”
Comment:  Should also include “DSS and SSA as appropriate” for this particular service.

Community Engagement

Page 102 - Criteria/Allowable Activities
Paragraph 1 - Last Sentence
Comment:  Underlined sentence is confusing.  Should “community engagement” be substituted for “supported employment”?

Page 104 - 7^th Bullet:
Comment:  ADD “independent” before “living skills”

Group Day Services

Page 112 - Service Definition/Description
1^st Paragraph - Last Sentence:  DELETE “these services”.

Page 114:  Semi-Predictable Events
Paragraph 1:  States “The provider may request between 3-5 hours of additional “community engagement” per week that will allow the individual to choose additional community outings.
Comment:   Shouldn’t this read:  “The provider may request between 3-5 hours of additional “group day” services per week that will allow the individual to choose additional “group day” activities.  It is not clear.  If Community Engagement - then it should be included in the Community Engagement service section,

DD Waiver Manual - Chapter 4 - Part 2 of 2
30-Day Public Comment - vaACCSES

Supported Employment Services

Page 119: Criteria/Allowable Activities
Comment: 

• Recommend that bullets be entirely realigned AND be delineated between Individual SE and Group SE.
• The first sentence indicates that there is one element that is limited to ISE only. However, there are seven elements listed and are provided in GSE services. The “this element is limited…” should be at the end of the previous bullet.  It should state - “Individual job development, with or without the individual present that produces an appropriate job match for the individual and the employer to include job analysis or determining job tasks, or both. This element is limited to ISE only and is not permitted for GSE”
• Allowable activities should allow for reimbursement for collateral contacts, including Workplace Assistance if the service is provided. 
• Staff provision of transportation – need criteria for what is considered “unavailable or inaccessible” and how this is to be documented. 

• States - “For DMAS reimbursement to occur, the individual must be present, unless otherwise noted, when these activities occur:  Vocational or job-related discovery or assessment,

Supports to ensure the individual's health and safety during the hours of work”
Comment: We recommend that the above allowable activities be noted that these activities can be conducted without the individual being present.  In fact, many discovery and assessment documents are reviewed in the absence of the individual.  Furthermore, the coordination and logistics of arranging health and safety supports, such as coordination with the employment site or family members, would precede the implementation and therefore occur without the individual being present.

Page 120: Customized Employment
Comment:  There is nothing indicated in the manual regarding who may provide this service. Under DARS funded CE only ACRE Customized Employment certified specialists may provide this service – is this the expectation for DBHDS or can any ISE employment specialist provide it?

Page 120 - Job Search Planning
Comment:  the following “conduct an analysis of benefits which may be accessed through Benefits Planning” is unclear. Benefits planning is a separate service.  What is the “analysis of benefits” that is being referred to? While most employment specialists can identify when an individual would need that service, it is the role of the support coordinator to refer for the service and coordinate services.  

Page 122: Documentation of the Individual’s Ineligibility for SE Services
5^th Bullet:  States “Documentation of the individual’s ineligibility for supported employment service through DARS or IDEA, as applicable. If the individual is ineligible to receive service through IDEA, documentation is required only for lack of DARS funding. Acceptable documentation for the lack of DARS or IDEA funding would include a letter from either DARS or the local school system or a record of a telephone call, including name, date, and person contacted, documented either in the individual's file maintained by the support coordinator, on the ISP, or on the supported employment provider's supporting documentation. Unless the individual's circumstances change, for example, the individual is seeking a new job, the original verification may be forwarded into the current record or repeated on the supporting documentation on an annual basis”
Comment: We recommend that the responsibility for documenting Waiver ineligibility based on DARS or IDEA eligibility should be the responsibility of the Support Coordinator and should be indicated as a Support Coordinator responsibility instead of a provider responsibility.

Workplace Assistance

Page 124: Criteria/Allowable Activities
Comment:  ADD “This service is designed to support individuals in competitive, integrated positions for whom all options for independence in regards to appropriate job match, reasonable accommodations, and the utilization of natural supports in the workplace have been explored, exhausted and documented. This service is supplementary to individual supported employment in order to maintain stability in the workplace.”

Page 124 - Paragraph 1
Comment:  Includes a typo. Should read “has learned the basic skills…”

Additionally, there should be information under criteria indicating that natural supports and accommodations are not available for the identified support needs.

Skilled Nursing Services

Overall Comment - Page 140 - 2^nd to last bullet - There is a significant change in the Manual which is in conflict with the DD Waiver regulations regarding the period for which an authorization is completed.  The change is more prescriptive than the regulations and changes the 1-year authorization in line with an individual’s ISP year to a 6-month authorization. The Manual should not be more prescriptive than the regulations.  This places additional burden on providers. A change in this policy needs to go through the regulatory process or legislative process for full vetting.

Group Home Residential

Page 150 - Service Limitations

Comment:  Regulation 12VAC30-122-390 says “March 31, 2021” and the Manual says “May 1, 2021”  Consistency is needed between regulations and Manual.

Page 153 - 1^st Paragraph - Last Sentence

Comment:  Manual states “Each quarterly review will represent the quarterly data.  However, the fourth quarter will provide an annual summary in addition to the fourth quarter data.  This is not authorized in regulations.  Inconsistent.

Sponsored Residential
Page 175 - Last Bullet
Comment:  DELETE last sentence “Four written reviews span the entire ISP year.”  Language is not consistent with other residential services.

Consumer Directed Services & Services Facilitation

Page 203
Comment:  After the description of CD services in general, and before the beginning of what is currently on Page 204, we recommend that you add the following regulatory language in the Manual for clarification and consistency - 12VAC30-122-150, A, 2, d, e, and f

Page 204 - Bullet 1 --
Comment: Recommend clarification around whether or not the EOR must live with the individual receiving services.  Providers often get “pended” for this. 

Page 204 - Last paragraph -  After the first sentence, ADD “If the individual chooses not to have service facilitation, the support coordinator must document which family member or caregiver other than the EOR shall perform all of the duties and meet all of the requirements of a CD services facilitator.”  (VAC1230-122-150, A, 2, e)

Page 205 - Paragraph 3 - “When two individuals who live in the same home….”.  Recommend ADD “If the individual has chosen not to have Services Facilitation, then the family member or caregiver acting in that capacity will be responsible this assessment.”

Page 205 - Paragraph 4 - Recommend the first sentence to say “An individual who has chosen consumer direction may choose, at any time, to voluntarily change all or part of their services to the agency-directed model as long as he/she/they continues to qualify for the specific services.”
Comment:  For example, he/she/they may choose to move just Respite or part of the Personal Care hours to agency, while maintaining all, or a portion of their Personal Care under the consumer-directed model of service.”  Recommend the second sentence in that paragraph to read, “The services facilitator, or family member or caregiver acting in that capacity, and the support coordinator are responsible for assisting….”

Page 205 - Last bullet - If the change recommended above for Rec 1is adopted - this bullet can remain as is.

Page 207 - Paragraph 1 - This is the explanation that needs to be moved up or copied in the CD section above SF.  See recommendation #1.

Page 207 - Paragraph 3 - The second to last sentence in this part is not proper grammar. Recommend - “Transitions from the CCC Plus Waiver to a DD waiver will only occur only on the first day of a month.”  Also, the last sentence should read, “The SF, or family member or caregiver acting in that capacity, has a role to play in this process in order to ensure continuity of care.”

Page 207 - Last Section  Bullet 2 - there needs to be a space between the words "should" and "call" in the last sentence.

Page 208 - Bullet 5 - Recommend to read “For consumer-directed services, the services facilitator, or family member or caregiver acting in that capacity, must submit the Fiscal Agent Request Form to the FE/A and initiate the change in discal employer agent, if applicable, and the change from CCC Plus Waiver services to DD Waiver services.”

Page 209 - Last Bullet - Language is different from regulations - needs consistency and not more prescriptive language. The regs (12VAC30-122-500, B, 4) state “The services facilitator, during routine quarterly visits, shall also review and verify….”  The manual states “routine semi-annual visits”.  This language should be changed to match the regs. The manual should also add “or family member or caregiver acting in that capacity” to that sentence as well. 

Page 210 - Bullet 1 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must be available during standard business hours to the individual or EOR by telephone.”

Page 210 - Bullet 2 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, will assist the individual or EOR….”

Page 210 - Bullet 3 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must complete the assessments, ….”

Page 210 - Bullet 4 - Language inconsistent with regulations.  The regs (12VAC30-122-500, B, 8) state “Service facilitation service shall be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but at a minimum quarterly routine visits shall take place.”  The manual has been changed to say, “Services facilitation will be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but, at a minimum, routine semi-annual visits.” The manual should be changed to match the regs.  Also, the language “or family member or caregiver acting in that capacity” needs to be added. 

Page 210 - Last Sentence - Recommend language change to “The SF, or family member or caregiver acting in that capacity, may not be the individual enrolled….”

Page 211 - 1^st Sentence - Recommend language change to “The SF, or family member or caregiver acting in that capacity, must document….”

Page 211 - 2^nd Sentence - Recommend language change to “Should a CD employee not report for work or terminate employment without notice, the SF or family member or caregiver acting in that capacity, upon the individual’s or EOR’s request….”

Page 211 - Service Documentation & Requirements -

• 1^st Sentence - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must maintain….”
• Bullet 1  - Recommend language change to “his” to “his/her/they” in sentence, “….receipt of training on his responsibility for the accuracy….”
• Bullet 2  - Typo - "hat" should be "that"
• Bullet 3 -  What is considered a “contact”?  This needs clarification.  Also, what is considered “medical record

Page 212 - Bullet 2 -  
Comment:  Language in the Manual should match the regulations. The Manual Language is more prescriptive. The manual reads, “In a situation whereby the individual’s needs have changed significantly, the plan for supports must be reviewed by the provider.”  The regs (12VAC30-122-500, E, 3, g) state “Documentation indicating that desired outcomes and support activities of the plan for supports have been reviewed by the consumer-directed services facilitator provider quarterly, annually, and more often as needed.”  Manual pg 212, bullet 2, the sub-bullets à These sub-bullets do not exist in the regs.  Why are we being made to document MORE than what is in the regs???  Isn’t that considered more restrictive than the regs?

Page 212 - Bullet 3 - It is missing the number of calendar days in the language.  Also, there is no time limit in the regs, so any introduction of a time limit on when the review must be submitted to the Support Coordinator is more restrictive than the regs. 

Page 212 - Bullet 3 - Sub-Bullet 1 - There is no sub-bullet in the regulations.  This needs to be a dark bullet and moved to the left to align with the other bullets.  

Supported Employment Services

Page 119: Criteria/Allowable Activities
Comment: 

• Recommend that bullets be entirely realigned AND be delineated between Individual SE and Group SE.
• The first sentence indicates that there is one element that is limited to ISE only. However, there are seven elements listed and are provided in GSE services. The “this element is limited…” should be at the end of the previous bullet.  It should state - “Individual job development, with or without the individual present that produces an appropriate job match for the individual and the employer to include job analysis or determining job tasks, or both. This element is limited to ISE only and is not permitted for GSE”
• Allowable activities should allow for reimbursement for collateral contacts, including Workplace Assistance if the service is provided. 
• Staff provision of transportation – need criteria for what is considered “unavailable or inaccessible” and how this is to be documented. 

• States - “For DMAS reimbursement to occur, the individual must be present, unless otherwise noted, when these activities occur:  Vocational or job-related discovery or assessment,

Supports to ensure the individual's health and safety during the hours of work”
Comment: We recommend that the above allowable activities be noted that these activities can be conducted without the individual being present.  In fact, many discovery and assessment documents are reviewed in the absence of the individual.  Furthermore, the coordination and logistics of arranging health and safety supports, such as coordination with the employment site or family members, would precede the implementation and therefore occur without the individual being present.

Page 120: Customized Employment
Comment:  There is nothing indicated in the manual regarding who may provide this service. Under DARS funded CE only ACRE Customized Employment certified specialists may provide this service – is this the expectation for DBHDS or can any ISE employment specialist provide it?

Page 120 - Job Search Planning
Comment:  the following “conduct an analysis of benefits which may be accessed through Benefits Planning” is unclear. Benefits planning is a separate service.  What is the “analysis of benefits” that is being referred to? While most employment specialists can identify when an individual would need that service, it is the role of the support coordinator to refer for the service and coordinate services.  

Page 122: Documentation of the Individual’s Ineligibility for SE Services
5^th Bullet:  States “Documentation of the individual’s ineligibility for supported employment service through DARS or IDEA, as applicable. If the individual is ineligible to receive service through IDEA, documentation is required only for lack of DARS funding. Acceptable documentation for the lack of DARS or IDEA funding would include a letter from either DARS or the local school system or a record of a telephone call, including name, date, and person contacted, documented either in the individual's file maintained by the support coordinator, on the ISP, or on the supported employment provider's supporting documentation. Unless the individual's circumstances change, for example, the individual is seeking a new job, the original verification may be forwarded into the current record or repeated on the supporting documentation on an annual basis”
Comment: We recommend that the responsibility for documenting Waiver ineligibility based on DARS or IDEA eligibility should be the responsibility of the Support Coordinator and should be indicated as a Support Coordinator responsibility instead of a provider responsibility.

Workplace Assistance

Page 124: Criteria/Allowable Activities
Comment:  ADD “This service is designed to support individuals in competitive, integrated positions for whom all options for independence in regards to appropriate job match, reasonable accommodations, and the utilization of natural supports in the workplace have been explored, exhausted and documented. This service is supplementary to individual supported employment in order to maintain stability in the workplace.”

Page 124 - Paragraph 1
Comment:  Includes a typo. Should read “has learned the basic skills…”

Additionally, there should be information under criteria indicating that natural supports and accommodations are not available for the identified support needs.

Skilled Nursing Services

Overall Comment - Page 140 - 2^nd to last bullet - There is a significant change in the Manual which is in conflict with the DD Waiver regulations regarding the period for which an authorization is completed.  The change is more prescriptive than the regulations and changes the 1-year authorization in line with an individual’s ISP year to a 6-month authorization. The Manual should not be more prescriptive than the regulations.  This places additional burden on providers. A change in this policy needs to go through the regulatory process or legislative process for full vetting.

Group Home Residential

Page 150 - Service Limitations

Comment:  Regulation 12VAC30-122-390 says “March 31, 2021” and the Manual says “May 1, 2021”  Consistency is needed between regulations and Manual.

Page 153 - 1^st Paragraph - Last Sentence

Comment:  Manual states “Each quarterly review will represent the quarterly data.  However, the fourth quarter will provide an annual summary in addition to the fourth quarter data.  This is not authorized in regulations.  Inconsistent.

Sponsored Residential
Page 175 - Last Bullet
Comment:  DELETE last sentence “Four written reviews span the entire ISP year.”  Language is not consistent with other residential services.

Consumer Directed Services & Services Facilitation

Page 203
Comment:  After the description of CD services in general, and before the beginning of what is currently on Page 204, we recommend that you add the following regulatory language in the Manual for clarification and consistency - 12VAC30-122-150, A, 2, d, e, and f

Page 204 - Bullet 1 --
Comment: Recommend clarification around whether or not the EOR must live with the individual receiving services.  Providers often get “pended” for this. 

Page 204 - Last paragraph -  After the first sentence, ADD “If the individual chooses not to have service facilitation, the support coordinator must document which family member or caregiver other than the EOR shall perform all of the duties and meet all of the requirements of a CD services facilitator.”  (VAC1230-122-150, A, 2, e)

Page 205 - Paragraph 3 - “When two individuals who live in the same home….”.  Recommend ADD “If the individual has chosen not to have Services Facilitation, then the family member or caregiver acting in that capacity will be responsible this assessment.”

Page 205 - Paragraph 4 - Recommend the first sentence to say “An individual who has chosen consumer direction may choose, at any time, to voluntarily change all or part of their services to the agency-directed model as long as he/she/they continues to qualify for the specific services.”
Comment:  For example, he/she/they may choose to move just Respite or part of the Personal Care hours to agency, while maintaining all, or a portion of their Personal Care under the consumer-directed model of service.”  Recommend the second sentence in that paragraph to read, “The services facilitator, or family member or caregiver acting in that capacity, and the support coordinator are responsible for assisting….”

Page 205 - Last bullet - If the change recommended above for Rec 1is adopted - this bullet can remain as is.

Page 207 - Paragraph 1 - This is the explanation that needs to be moved up or copied in the CD section above SF.  See recommendation #1.

Page 207 - Paragraph 3 - The second to last sentence in this part is not proper grammar. Recommend - “Transitions from the CCC Plus Waiver to a DD waiver will only occur only on the first day of a month.”  Also, the last sentence should read, “The SF, or family member or caregiver acting in that capacity, has a role to play in this process in order to ensure continuity of care.”

Page 207 - Last Section  Bullet 2 - there needs to be a space between the words "should" and "call" in the last sentence.

Page 208 - Bullet 5 - Recommend to read “For consumer-directed services, the services facilitator, or family member or caregiver acting in that capacity, must submit the Fiscal Agent Request Form to the FE/A and initiate the change in discal employer agent, if applicable, and the change from CCC Plus Waiver services to DD Waiver services.”

Page 209 - Last Bullet - Language is different from regulations - needs consistency and not more prescriptive language. The regs (12VAC30-122-500, B, 4) state “The services facilitator, during routine quarterly visits, shall also review and verify….”  The manual states “routine semi-annual visits”.  This language should be changed to match the regs. The manual should also add “or family member or caregiver acting in that capacity” to that sentence as well. 

Page 210 - Bullet 1 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must be available during standard business hours to the individual or EOR by telephone.”

Page 210 - Bullet 2 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, will assist the individual or EOR….”

Page 210 - Bullet 3 - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must complete the assessments, ….”

Page 210 - Bullet 4 - Language inconsistent with regulations.  The regs (12VAC30-122-500, B, 8) state “Service facilitation service shall be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but at a minimum quarterly routine visits shall take place.”  The manual has been changed to say, “Services facilitation will be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but, at a minimum, routine semi-annual visits.” The manual should be changed to match the regs.  Also, the language “or family member or caregiver acting in that capacity” needs to be added. 

Page 210 - Last Sentence - Recommend language change to “The SF, or family member or caregiver acting in that capacity, may not be the individual enrolled….”

Page 211 - 1^st Sentence - Recommend language change to “The SF, or family member or caregiver acting in that capacity, must document….”

Page 211 - 2^nd Sentence - Recommend language change to “Should a CD employee not report for work or terminate employment without notice, the SF or family member or caregiver acting in that capacity, upon the individual’s or EOR’s request….”

Page 211 - Service Documentation & Requirements -

• 1^st Sentence - Recommend language change to “The services facilitator, or family member or caregiver acting in that capacity, must maintain….”
• Bullet 1  - Recommend language change to “his” to “his/her/they” in sentence, “….receipt of training on his responsibility for the accuracy….”
• Bullet 2  - Typo - "hat" should be "that"
• Bullet 3 -  What is considered a “contact”?  This needs clarification.  Also, what is considered “medical record

Page 212 - Bullet 2 -  
Comment:  Language in the Manual should match the regulations. The Manual Language is more prescriptive. The manual reads, “In a situation whereby the individual’s needs have changed significantly, the plan for supports must be reviewed by the provider.”  The regs (12VAC30-122-500, E, 3, g) state “Documentation indicating that desired outcomes and support activities of the plan for supports have been reviewed by the consumer-directed services facilitator provider quarterly, annually, and more often as needed.”  Manual pg 212, bullet 2, the sub-bullets à These sub-bullets do not exist in the regs.  Why are we being made to document MORE than what is in the regs???  Isn’t that considered more restrictive than the regs?

Page 212 - Bullet 3 - It is missing the number of calendar days in the language.  Also, there is no time limit in the regs, so any introduction of a time limit on when the review must be submitted to the Support Coordinator is more restrictive than the regs. 

Page 212 - Bullet 3 - Sub-Bullet 1 - There is no sub-bullet in the regulations.  This needs to be a dark bullet and moved to the left to align with the other bullets.  

Quality Management and Utilization Reviews

Introduction
Page 1:

• First paragraph, 2^nd sentence - who is DMAS’s “designated agent”? Recommend clarification between DMAS QMR staff and any subcontracted contractor for financial audits, etc.
• First paragraph, 4^th sentence states “DMAS conducts compliance reviews on providers that are found to provide services in excess of established norms, ..."
  Comment:  Shouldn't this be just on those that do not provide services in accordance with the regulations?  What does "established norms" mean? Language needs to be changed or definition of “established norms” needs to be provided.

General Requirements
Page 1:

• Second paragraph, 1st sentence states "DMAS participation standards and policies".
  Comment:  Shouldn’t this refer to regulations as in the following sentence?  If “standards and policies” is retained - definition or citation needs to be included.

Page 2:

• 1^st sentence - general grammar problem - comma needed following the word "individuals”.
• Second paragraph, 1st sentence - Who is "staff"?  We assume “DMAS QMR staff” in this instance.
  Comment:  Helpful to state and delineate between DMAS QMR staff and provider staff within this paragraph and others to provide clarity. Also, "staff may request licenses” - However, not all providers are required to have staff that is licensed. Add “providers and staff required to have licenses”.  Differentiate between requirements of services that are licensed and services that are not licensed regarding criminal background checks and what “documentation” is required.

• Third paragraph, 2nd sentence - Again, the requirement to be in compliance with "DMAS provider agreements and policies"
  Comment:  Shouldn’t this refer to regulations?  If “standards and policies” is retained - definition or citation needs to be included for clarity.

• Fourth paragraph, 3rd sentence - Use of the word "provider" here. 
  Comment:  Assume this means the Agency Provider and not the Personal Care provider. However, “provider” is used interchangeably for both throughout document. “Staff” is also used interchangeably throughout the document. Clarity and specificity is needed consistently.

Page 3:

• Bullet 1, 1st sentence - states "within the program's guidelines"?  Should this be "in accordance with regulations"?
• Bullet 1, 2nd sentence - Same comment as above related to the use of the word "provider".
• Bullet 1, 3rd sentence -
  Comment:  What is considered to be "the individual's record"?  Add specific reference to what record.  Is it enough to document these things in a provider’s system?  Also, what is classified as "any substantial change"?  And what specific "documentation of such change" is required? Please add specificity.
• Bullet 1, 4th sentence - Recognize that provider’s responsibility to identify “substantial changes” and inform the Support Coordinator. 
  Comment:  However, it is the Support Coordinator’s role to obtain and coordinate those services that the individual requires to remain in the community and not the provider. The "or" that follows that requirement should be replaced with "so that the Support Coordinator can obtain any other services,...."
• Bullet 3, 2nd sentence - Clarity needed.
  Comment:  Who is considered "provider staff"?  and who is the "provider agency representative"?  In the case of Service Facilitation - clarity is needed since the SF is the one both in communication with the individual AND the one responsible for the oversight of the plan.
• Manual Pg 3, bullet 3, last sentence à where should the "providers" find the remaining list of quality of supports if this is just "some" of them?  Remember, not every provider is licensed, so we are only following the regulations and this handbook.
• Manual Pg 3, bullet 4 à are we allowed to use electronic signature now?  Where did that change in the regulations?

Page 4:

• Bullet 1 - Use of "provider" again and "maintain a record"? 
  Comment:  Can that be just be in the provider’s system?  It's confusing since the next sentence mentions the forms.  So is the "record" the "form"?  Are those one and the same?  Why not use the same word for both spots?
• 1st full paragraph - "DMAS will review the provider's performance in all the outcome areas to determine the provider's ability to achieve high quality supports..." 
  Comment:  This is where that word "provider" gets used interchangeably again.  The SF writes outcomes based on the Part 3, but the outcomes are for the Personal Care Attendant to provide to the individual and not for the SF to provide to the individual.  So, who is the "provider" whose performance DMAS is reviewing? Further clarification is needed.
• General Comment on consistency - The language is now referring to DMAS.  "DMAS will review", "DMAS will evaluate", "DMAS may require".  Before, in this same document, it refers to "staff".  Consistency is needed throughout.
• 2nd full paragraph - Shouldn’t the regulations be mentioned here instead of “policies and procedures”?
• Bullet 1 - Further clarity is needed.  What exactly is meant by "periodically"?
• Bullet 5, sentence 1  - A sentence is needed to differentiate Service Facilitation and CD services from other services and their specific requirements. States "Staff" will meet with at least one individual or PCG to determine satisfaction with the provider.  Which provider is that?  The SF provider agency?  Or the PCA provider?  Not clear regarding what would be measured for SF. 

Page 5:

• Bullet 1 - why is "provider" underlined?  Who is "staff"?  Appreciate the reference to regulations vs “policies and procedures”.   
• Bullet 3  - Who is submitting this letter to these other agencies? Specificity needed.

Comprehensive and Ongoing Assessment and Planning

Page 8:  Bullet 1, sub-bullet 5 - A parenthesis is missing here.

Page 10: Bullet 3 - Why is "the waiver enrollment date" underlined?

Services are Delivered, Reviewed and Modified as Needed
Page 11:   
Comment:  Is this for all providers or specific to Case Management?  The first bullet/sub-bullet seems to speak to each service provider, but then the second sub-bullet is specific to Case Management.  Then the third sub-bullet goes back to "each service provider".  Recommend to separate and list bullets under either provider and case management for clarity

Page 12:  Main Bullet
Comment:  Sub-bullet 1 - Provide specificity in Manual. What DMAS form is to be used for the quarterly review?  There is currently no consistency from CSB to CSB on what documentation is required to be used for quarterlies.  There is also no consistency as to what has to be in that quarterly review.  Specificity would be helpful to provide consistency.

Page 13: 

• 1st sub-bullet à "All providers must be invited to the meeting and participate in the development of the new ISP annually."  Are SF required to be present at the meeting?  Service Facilitators are not compensated for this meeting and can only bill for a reassessment visit. These meetings can be up to 3+ hours.

Services Delivered are Consistent With Service Limits
Page 13:  Bullet 1, sub-bullet 2 -
Comment:  Need additional specificity for Service Facilitation - recommend separate sub-bullet. "The number of hours does require authorization."  What hours?  MT Units?  PCA hours?  Respite Hours?  Companion Hours?  The hours the SF is working?

Page 15: Bullet 2
Comment:  Paper timesheets went away a long time ago, so the EOR and employee will not be signing them.  Time is either logged via app, online portal, or by calling in using IVR.  So billing for CD services will not be supported by a timesheet that is signed.  This point in the manual needs to be removed.

Support Coordinator/Case Manager/Provider Responsibilities
Page 23:
Comment:  Need to REMOVE “Provider” from this section. “Provider” should not be included in this title when the first paragraph says that the following things are the responsibility of the support coordinator/case manager, and doesn't mention the provider?  None of the things listed are the responsibility of the provider. 

DD Waiver Manual - Chapter 6 - 30-Day Public Comment - vaACCSES

Quality Management and Utilization Reviews

Introduction
Page 1:

• First paragraph, 2^nd sentence - who is DMAS’s “designated agent”? Recommend clarification between DMAS QMR staff and any subcontracted contractor for financial audits, etc.
• First paragraph, 4^th sentence states “DMAS conducts compliance reviews on providers that are found to provide services in excess of established norms, ..."
  Comment:  Shouldn't this be just on those that do not provide services in accordance with the regulations?  What does "established norms" mean? Language needs to be changed or definition of “established norms” needs to be provided.

General Requirements
Page 1:

• Second paragraph, 1st sentence states "DMAS participation standards and policies".
  Comment:  Shouldn’t this refer to regulations as in the following sentence?  If “standards and policies” is retained - definition or citation needs to be included.

Page 2:

• 1^st sentence - general grammar problem - comma needed following the word "individuals”.
• Second paragraph, 1st sentence - Who is "staff"?  We assume “DMAS QMR staff” in this instance.
  Comment:  Helpful to state and delineate between DMAS QMR staff and provider staff within this paragraph and others to provide clarity. Also, "staff may request licenses” - However, not all providers are required to have staff that is licensed. Add “providers and staff required to have licenses”.  Differentiate between requirements of services that are licensed and services that are not licensed regarding criminal background checks and what “documentation” is required.

• Third paragraph, 2nd sentence - Again, the requirement to be in compliance with "DMAS provider agreements and policies"
  Comment:  Shouldn’t this refer to regulations?  If “standards and policies” is retained - definition or citation needs to be included for clarity.

• Fourth paragraph, 3rd sentence - Use of the word "provider" here. 
  Comment:  Assume this means the Agency Provider and not the Personal Care provider. However, “provider” is used interchangeably for both throughout document. “Staff” is also used interchangeably throughout the document. Clarity and specificity is needed consistently.

Page 3:

• Bullet 1, 1st sentence - states "within the program's guidelines"?  Should this be "in accordance with regulations"?
• Bullet 1, 2nd sentence - Same comment as above related to the use of the word "provider".
• Bullet 1, 3rd sentence -
  Comment:  What is considered to be "the individual's record"?  Add specific reference to what record.  Is it enough to document these things in a provider’s system?  Also, what is classified as "any substantial change"?  And what specific "documentation of such change" is required? Please add specificity.
• Bullet 1, 4th sentence - Recognize that provider’s responsibility to identify “substantial changes” and inform the Support Coordinator. 
  Comment:  However, it is the Support Coordinator’s role to obtain and coordinate those services that the individual requires to remain in the community and not the provider. The "or" that follows that requirement should be replaced with "so that the Support Coordinator can obtain any other services,...."
• Bullet 3, 2nd sentence - Clarity needed.
  Comment:  Who is considered "provider staff"?  and who is the "provider agency representative"?  In the case of Service Facilitation - clarity is needed since the SF is the one both in communication with the individual AND the one responsible for the oversight of the plan.
• Manual Pg 3, bullet 3, last sentence à where should the "providers" find the remaining list of quality of supports if this is just "some" of them?  Remember, not every provider is licensed, so we are only following the regulations and this handbook.
• Manual Pg 3, bullet 4 à are we allowed to use electronic signature now?  Where did that change in the regulations?

Page 4:

• Bullet 1 - Use of "provider" again and "maintain a record"? 
  Comment:  Can that be just be in the provider’s system?  It's confusing since the next sentence mentions the forms.  So is the "record" the "form"?  Are those one and the same?  Why not use the same word for both spots?
• 1st full paragraph - "DMAS will review the provider's performance in all the outcome areas to determine the provider's ability to achieve high quality supports..." 
  Comment:  This is where that word "provider" gets used interchangeably again.  The SF writes outcomes based on the Part 3, but the outcomes are for the Personal Care Attendant to provide to the individual and not for the SF to provide to the individual.  So, who is the "provider" whose performance DMAS is reviewing? Further clarification is needed.
• General Comment on consistency - The language is now referring to DMAS.  "DMAS will review", "DMAS will evaluate", "DMAS may require".  Before, in this same document, it refers to "staff".  Consistency is needed throughout.
• 2nd full paragraph - Shouldn’t the regulations be mentioned here instead of “policies and procedures”?
• Bullet 1 - Further clarity is needed.  What exactly is meant by "periodically"?
• Bullet 5, sentence 1  - A sentence is needed to differentiate Service Facilitation and CD services from other services and their specific requirements. States "Staff" will meet with at least one individual or PCG to determine satisfaction with the provider.  Which provider is that?  The SF provider agency?  Or the PCA provider?  Not clear regarding what would be measured for SF. 

Page 5:

• Bullet 1 - why is "provider" underlined?  Who is "staff"?  Appreciate the reference to regulations vs “policies and procedures”.   
• Bullet 3  - Who is submitting this letter to these other agencies? Specificity needed.

Comprehensive and Ongoing Assessment and Planning

Page 8:  Bullet 1, sub-bullet 5 - A parenthesis is missing here.

Page 10: Bullet 3 - Why is "the waiver enrollment date" underlined?

Services are Delivered, Reviewed and Modified as Needed
Page 11:   
Comment:  Is this for all providers or specific to Case Management?  The first bullet/sub-bullet seems to speak to each service provider, but then the second sub-bullet is specific to Case Management.  Then the third sub-bullet goes back to "each service provider".  Recommend to separate and list bullets under either provider and case management for clarity

Page 12:  Main Bullet
Comment:  Sub-bullet 1 - Provide specificity in Manual. What DMAS form is to be used for the quarterly review?  There is currently no consistency from CSB to CSB on what documentation is required to be used for quarterlies.  There is also no consistency as to what has to be in that quarterly review.  Specificity would be helpful to provide consistency.

Page 13: 

• 1st sub-bullet à "All providers must be invited to the meeting and participate in the development of the new ISP annually."  Are SF required to be present at the meeting?  Service Facilitators are not compensated for this meeting and can only bill for a reassessment visit. These meetings can be up to 3+ hours.

Services Delivered are Consistent With Service Limits
Page 13:  Bullet 1, sub-bullet 2 -
Comment:  Need additional specificity for Service Facilitation - recommend separate sub-bullet. "The number of hours does require authorization."  What hours?  MT Units?  PCA hours?  Respite Hours?  Companion Hours?  The hours the SF is working?

Page 15: Bullet 2
Comment:  Paper timesheets went away a long time ago, so the EOR and employee will not be signing them.  Time is either logged via app, online portal, or by calling in using IVR.  So billing for CD services will not be supported by a timesheet that is signed.  This point in the manual needs to be removed.

Support Coordinator/Case Manager/Provider Responsibilities
Page 23:
Comment:  Need to REMOVE “Provider” from this section. “Provider” should not be included in this title when the first paragraph says that the following things are the responsibility of the support coordinator/case manager, and doesn't mention the provider?  None of the things listed are the responsibility of the provider. 

DD Waiver Manual - Chapter 4 - Part 1 of 2
30-Day Public Comment - vaACCSES

GENERAL COMMENTS:

1. Purpose of Manual to provide explanation, clarification, definition, examples, possible service scenarios, and interpretation for providers to deliver consistent implementation of quality services, documentation and required reports across the Commonwealth. However, we have found that there are numerous items in the Manual that are more prescriptive than what is included within DD Waiver regulatory authority - which is problematic. The Manual should not be more prescriptive than regulations since the governing authority are the regs. The addition of regulatory citations would help as reference throughout the Manual as appropriate. 
2. Consistency between Regulations and Manual is critical.  There are multiple examples throughout the Manual of inconsistencies between licensing regulations, DD Waiver regulations and what’s required by DMAS in the Provider Agreement.  All of this makes it confusing for the provider and creates additional administrative burden.  It also complicates the rules for providers that provide “unlicensed services”.  Because the service is unlicensed, it makes it difficult to know and fulfill requirements that refer to the licensing regulations and/or to forms referenced.
3. Chart with “Corresponding Regulations” and BI, FI and CL columns are a helpful visual and provide clarity regarding regulation reference at the beginning of each service.  We recommend that a chart be used for all services in Chapter 4. (See page 78 as example).
4. There is an overall need to clearly delineate the responsibilities and requirements for support coordinator actions versus service provider actions.  Ideally, support coordination would either have a companion Manual or minimally, within the Waiver manual, have clear sections within chapters and/or services. Possibly, even a separate chapter with ONLY the Support Coordination requirements and responsibilities. The lack of separation and specificity are confusing regarding responsibility and requirements of “providers” throughout the Manual.  The question asked often throughout is “which provider is responsible”.
5. We request that overall instructions on how providers should round any fractions of service hours provided for billing purposes. This is not included in the current Manual but would be very helpful as an overall instruction to provide specification and consistency. In the past when we asked, we were told that these instructions were to be included in the future Manual in a chapter for “other services”.  It would of course be efficient to include this information within the Waiver manual.

CHAPTER 4:

Table of Contents & Service Option Charts:
Corrections Needed:

• Individual & Family/Caregiver Training is incorrectly marked as included in the BI waiver - should be FIS Waiver
• Workplace Assistance Services is incorrectly marked as only being included in the FIS Waiver - it is also included in the CL Waiver.

Page 1 - Criteria to Be Eligible -
Comment:  What if they do not have "functional limitations in major life activities" - but might need Companion Care or Sensory Equipment (AT or DME)?

Diagnostic Eligibility

Page 2, paragraph 1:
COMMENT:  Correction Needed. Paragraph refers to “three of more criteria described in (1) through (5) above…”  Please change bullets to numbers for clarity.

Day Assessment Service Authorization Requests

Page 22:

Comment:  Would prefer that the language used provide additional clarity than the 60-day assessment is an option (“may”) - but not required. Recommend - “Provider has the option to request a 60-day assessment prior to initiating plan for supports.”

Page 23:  Provider Discontinuation of Services.

Comment: Regarding 10 business days advanced notice in writing. This is not always possible. Individual Supported Employment (ISE) services, for example, will end when an individual quits or is terminated from a position and DARS categories are open. Would prefer language that better reflects that this is best practice when possible but not required. Additionally, it indicates that in a situation in which health/safety concerns are the reason for discharge, DBHDS must be notified – who at DBHDS is to be notified?

Assistive Technology (AT)  

General Comment: Assistive Technology (AT) is an HCBS waiver benefit that all recipients of DD waivers and CCC+ waivers are equally entitled to access in accordance with regulations at 12VAC30-122-270. Although there is only one regulation for AT, guidance for administration of it is inconsistent. AT requests for people with a DD waiver are approved by DBHDS according to the DD Waiver Manual Chapter IV and AT requests for people with the CCC+ waiver are approved by the MCO or KePRO according to the Durable Medical Equipment (DME) and Supplies Manual Chapter IV. Review of both manuals find extensive differences and variations, and both manuals are more restrictive than the AT regulations they are purported to clarify.

These contradictions and inconsistencies represent the root causes of many of the barriers that individuals, providers, and DMAS are experiencing as reported by the HB2197 working group that DMAS was charged with hosting to identify barriers to accessing AT and related services as well as options for removing them. Making the administrative manual changes recommended below will remove many of these barriers that impact over 30,000 people with disabilities. Only the DD Waiver Manual is open for public comment; the DME Manual was closed in June 2021 after receiving zero comments. We strongly urge DMAS to revise both Manuals to appropriately reflect the AT regulations at 12VAC30-122-270. Suggested revisions for both manuals are provided below.

Relevant Regs at 12VAC30-122-270.

Page 49 - Service Description - 2^nd to last sentence
Comment:  “Assistive technology devices are portable and authorized per calendar year” is inconsistent with the regulations, which do not require AT devices to be portable. Recommend DELETE “are portable and” to retain the calendar year portion of the sentence, which is consistent with the regulations.

Page 50 - Examples - Allowable Equipment Table

Comment:  Lists allowable equipment and activities that may include a limited list that does not fully reflect the allowable scope of AT in the regs because it lists both types of AT and purposes of AT. Specifically, the allowable list in the manual does not reference AT that enables an individual to actively participate in other waiver services. This purpose of AT is referenced in both the regulations and in the manual on the previous page that lists what AT is supposed to enable.

Recommend replacing the allowable equipment and services list on page 50 about the types of allowable AT to, “Allowable equipment and activities may include specialized medical equipment and ancillary equipment; durable or nondurable medical equipment and supplies; adaptive devices, appliances, and controls; and other equipment, devices, items, and software that meets the service definition.”

Page 51

Comment: This is a stand-alone exclusion that is neither supported by the regs nor referenced in the allowable items section of the regs or the manual, “Items such as furniture shall not be approved if they are of general utility and are not of direct medical benefit.” The regulations require an independent professional consultation that should determine on its own merit if the AT is needed to, “enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, or to participate in other waiver services. (12VAC30-122-270),” in order for the AT to be approved, making this additional stipulation unnecessary.

Recommend deletion of the entire sentence.

Page 51 -
Comment:  Sentence about software compatibility is more restrictive than regulations, “AT providers must ensure that requests for software are compatible with the individual’s current computer.” This assumes all individuals have a computer at all, let alone one that is compatible with every type of software that might be evaluated as necessary AT by an independent professional’s recommendation. The regulations are clear that the independent professional shall determine the most appropriate item(s) for the individual’s needs, which may be compatible with a device that they already own or may require upgrades, enhancements, or a separate device.

Recommend deletion of the entire sentence.

Page 51 - Service Units and Service Limitations - 1^st Bullet
Comment: “for a specific timeframe” does not clarify the implementation of the regulation. The only timeframe specified in the regulations at (12VAC30-122-270) is the budget limit for a calendar year, and many prior authorization systems only accept a 1-month service period for the AT code used for service authorization requests.

Recommend either deleting “for a specific timeframe” or revising to, “for the timeframe specified by the service authorization system.”

Page 52 - Service Units and Service Limitations Bullet about AT

Comment: under EPSDT for children is vague, confusing, and is more restrictive than the regulation. The regulation at (12VAC30-122-270) C.4. Service units and limitations says, “Requests for AT service via a DD Waiver shall be denied if the AT service is available under EPSDT.” Nowhere in any of the regulations are children under 21 limited to only AT available under EPSDT. Instead of instructions and guidance about how to coordinate the AT benefits that children are eligible to receive under both EPSDT and HCBS in order to comply with the regulation if the requested AT is not available to the child under EPSDT, the proposed manual language only says, “AT for individuals younger than 21 years of age must be accessed through the EPSDT benefit,” indicating children may only access AT under the EPSDT benefit.

Recommend revision: “AT for individuals younger than 21 years of age may be requested via a DD Waiver if the AT is not available to the child under EPSDT.”

Page 52 - Service Exclusions - 1^st Bullet
Comment:  Assumes all of the items listed will only ever be for the purposes of convenience, restraint, or recreational or leisure purposes. This administrative declaration circumvents and undermines the fundamental requirement for an independent, professional consultation/evaluation, and could restrict individuals from accessing the least expensive, most cost-effective manner of meeting the regulatory purpose of AT, “to enable individuals to increase abilities to perform ADLs; to perceive control, or communicate with their environment; to actively participate in other waiver services; or are necessary for the proper functioning (12VAC30-122-270)” of other equipment. As drafted, the manual permits service authorization staff to overrule the independent professional if any item related to those excluded, regardless of compliance with the regulations. Blanket exclusions are unnecessary and contradictory to the several pages of criteria, guidance, exclusions, and instructions in the manual that safeguard the AT fund for appropriate and compliant utilization.

Recommend deletion of the entire first bullet.

Page 53 - Last Bullet - Service Exclusions
Comment:  Same as regulation. Additional explanation or guidance would be appreciative. It is about duplication of payment for services that are reasonable accommodation requirements of the ADA and other Acts. What constitutes a duplication of payment? If an AT service is otherwise paid by whom? The HCBS AT budget? The Waiver? A Waiver provider? The State Plan? Another State entity? If the individual already has the AT that provides reasonable accommodation, then the independent professional would not recommend it as a needed item. Please describe a real-world example of a duplicate waiver payment for AT that supports this restriction.

Recommend revision with example that provides a better understanding of the regulation.

Page. 54 - Provider Documentation Requirements
Comment: states “Documentation in the Support Coordination record of notification by the individual or individual’s representative family/caregiver of satisfactory completion or receipt of the service or item.” This is supported in the regulations but is not a requirement that the AT provider can fulfill.

Recommend removing this bullet from the Provider Documentation Requirements and consider adding a separate Support Coordinator Requirements list and/or adding it to the Support Coordination Manual also currently open for public comment.

Page 54 Provider Documentation Requirements - Last Bullet -
Comment:  States for the “Support Coordinator to perform and document a face-to-face visit to assure that the individual can use the AT safely and appropriately.” Overly burdensome. This is not a requirement for provider documentation and is not supported in the regulations at (12VAC30-122-270). The other documentation requirements listed in the manual are copied from the regulations without additional detail or guidance, but this particular bullet does not reflect any requirement in the regulations for a face-to-face visit or assurance of safe and appropriate use. Only a professional trained in the AT item could make an assurance that the individual can use the AT safely and appropriately, which is part of the required independent professional consultation/evaluation.

Recommend deletion of the entire sentence.

Community Guide Services

Page 59 - 3rs Bullet - Documentation Requirements
Comment: States “Observations of the individual’s responses to the service must be available in at least a daily note”. Community Guide services are not necessarily provided on a daily basis.  Is this needed and realistic. Recommend deleting “daily” from note.

Electronic Home-Based Supports (EHBS)

General Comment:  The regs and the manual are aligned with one another in a way that only makes sense for equipment. In order for providers to deliver services under EHBS, the unit of service cannot be limited to only one.
Recommend Additional Language Be Added: "Only one unit of service is only appropriate for equipment or items that are delivered once. Services that include ongoing monitoring and other supports delivered electronically occur periodically and routinely as needed by the individual, similar to therapeutic consultation. Please consider separating administration of EHBS coverage of equipment from EHBS coverage of services to allow for appropriate and compliant service authorization and billing for ongoing services."

Page 63 - Service Documentation Requirements - Bullet #2
Comment:  This documentation is the requirement of the Support Coordinator and not the EHBS provider.

Individual and Family Caregiver Training

Page 70:
Indicates that contact notes, monthly notes, and quarterly reports must be completed. This is more than the regulations require.  Is also duplicative. It is also more information than is required for other services.  Other services require a quarterly review. Clarification is needed if monthly summaries are needed when there is a quarterly review being completed.

Transition Services

Page 74 Paragraph 1 and Page 75 Last Paragraph - Inconsistent language
Comment:  Page 74 includes language that an “individual has 30 days after transitioning to apply for Transition Services”.  Page 75 states that “service authorization must be obtained within 30 days of discharge.  Recommend clarification and consistent language be used to avoid confusion.

Benefits Planning
Page 90: Criteria/Allowable Activities
1^st Paragraph
Comment:  DELETE “or” before “employment status” and ADD “or need for work incentives”.

Page 94:
Paragraph 1:  Indicates that this service requires face to face contact.
Comment:  Regulations do not specify that this be a face-to-face contact.  Alternative options must be available including telehealth and virtual options. Overly prescriptive and not included in regulations.

Page 95: Mid-page - Bullet 1 -
Comment:  ADD “or is not available” after “have been explored and exhausted”.  Also, please clarify what documentation is needed to fulfill the requirement of “explored or exhausted”.

Page 95: Mid-page - Bullet 2 - Indicates there should be documentation of “All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS”
Comment:  Should also include “DSS and SSA as appropriate” for this particular service.

Community Engagement

Page 102 - Criteria/Allowable Activities
Paragraph 1 - Last Sentence
Comment:  Underlined sentence is confusing.  Should “community engagement” be substituted for “supported employment”?

Page 104 - 7^th Bullet:
Comment:  ADD “independent” before “living skills”

Group Day Services

Page 112 - Service Definition/Description
1^st Paragraph - Last Sentence:  DELETE “these services”.

Page 114:  Semi-Predictable Events
Paragraph 1:  States “The provider may request between 3-5 hours of additional “community engagement” per week that will allow the individual to choose additional community outings.
Comment:   Shouldn’t this read:  “The provider may request between 3-5 hours of additional “group day” services per week that will allow the individual to choose additional “group day” activities.  It is not clear.  If Community Engagement - then it should be included in the Community Engagement service section.