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10/15/21  9:33 am
Commenter: Tamara Starnes, BRBH

Mobile Crisis Teams, 2 LMHPs
 

The structure for Mobile Crisis Teams does not appear to have a scenario where two LMHP types respond together.  This is a common practice in many places around the Country and a valuable model. 

Recommend adding 2 LMHP types to the list. For example, could add to team scenario #5 , or create a 6th scenario. 2 LMHP types needs to be specified because LMHPs do register with the Board of Counseling as QMHPs and therefore do not meet the regulation as stated. 

CommentID: 110987
 

10/15/21  9:48 am
Commenter: Tamara Starnes, BRBH

Requirement for a call from the Crisis Hotline to provide Mobile Crisis
 

Recommend removing the requirement that a call from the "the Crisis Hotline" must happen . Only being able to access mobile crisis through a call to a hotline creates barriers to helping via the mobile crisis model. Access to Mobile Crisis services should be as wide open as possible, with help being able to be initiated from multiple referral sources. 

 A few examples not going through a hotline:  

Law enforcement agency calls directly for mobile crisis help as part of a local co-responder team. These teams will likely become more prevalent in Virginia as Marcus Alert rolls out.

A client walks-in to Same Day Access at a CSB and needs mobile crisis initiated. 

A family member calls their existing therapist because their child is  threatening suicide and wont' come out of the bedroom. The therapist calls local mobile crisis team. 

A hospital calls for a pre-screening. 

A community has EMS an Law Enforcement equipped with ipads to allow telehealth directly from on scene emergency calls. EMS and LE can connect directly with a mobile crisis team for evaluation. 

CommentID: 111002
 

10/15/21  10:00 am
Commenter: Tamara Starnes, BRBH

Correction: 2 LMHPS to respond to Mobile Crisis
 

Clarifying/Correction to previous comment: LMHP types DO NOT generally register with the Board of Counseling as QMHPs. This is an added cost and administrative burden and LMHP is a higher qualification. 

CommentID: 111021
 

10/22/21  2:32 pm
Commenter: Loren Johnson

Residential Crisis Stabilization
 
  1. Pg. 32 (First bullet): “A psychiatric evaluation by a psychiatrist, nurse practitioner or physician assistant must be available at the time of admission into the service.”
    1. Currently CSUs have 24 hours to complete the evaluation. Recommend clarifying the evaluation must be completed within 24 hours or immediately if an emergency arises. It is also not always good for a client who has been diverted by mobile crisis, or, sent from an ED, to have another evaluation immediately. Nursing vitals would be sufficient.
  2. Pg. 32 (Third bullet): “The Crisis Education and Prevention Plan (CEPP) meeting DBHDS requirements is required for this service and must be current. The CEPP process should be collaborative but must be directed and authorized by a LMHP, LMHP-R, LMHP-RP or LMHP-S.”
    1. The CEPP appears to be replacing the Treatment Plan. Currently Treatment Plans can be completed by QMHP’s and CSAC’s (and trainees). Recommend clarifying how involved the LMHP (and R/S/RP) need to be involved. Do they need to interview the client prior to the CEPP formulation and develop the Plan, or do they only need to be able to review/update and sign off on them?
    2. Recommend DBHDS publish their requirements for the CEPP prior to implementation.
  3. Pg. 32 (Sixth bullet, #3): “The following components must be available to individuals in the treatment program… 3. Nursing on-site 24/7.”

Pg. 35 (Staff Requirements, fifth paragraph): “Nursing services shall be provided by a RN or a LPN working directly under an RN who is present on the unit.”

    1. This is a change from previous, as on-site nursing was not required for Crisis Stabilization, only Withdrawal Management. Now, not only will nursing coverage be required 24/7, but a RN must be present at all times. This will present significant challenges for recruitment and staffing. Recommend Staff Requirements to say “Nursing services shall be provided by a RN or a LPN working directly under an RN who is either present on the unit or available by telephone.”
  1. Pg. 33 (#6): “Medical, psychological, psychiatric, laboratory, and toxicology services available by consult or referral;”
    1. For clarity, recommend “psychological” be replaced with “therapy,” as the usual convention referring to “psychological” treatment refers to care delivered by a psychologist.
    2. Recommend clarifying what “laboratory services” indicates. Does this refer to only being able to complete basic functions such as UDS, BAC, blood glucose readings, etc.? Or is there a need for full laboratory testing?
  2. Pg. 33 (First bullet): “On the day of admission, at a minimum, RCSU providers must provide assessment, psychiatric evaluation and a nursing assessment.”
    1. Currently, psychiatric evaluation is required to be completed within 24 hours, so may not be done on the day of admission. Evening admissions will often not be able to complete these three assessments before midnight. Recommend changing the time frame from “On the day of admission…” to “Within 24 hours of admission…”
  3. Pg. 33 (Second bullet): ” To bill the per diem on subsequent days during the admission, providers must provide daily individual, group or family therapy unless the LMHP, LMHP-R, LMHP-RP or LMHP-S documents the reason why therapy is not clinically appropriate…”
    1. Different clients have different needs. Rather than require the LMHP (S/R/RP) to document daily as to why individual, group, or family therapy is not clinically appropriate, recommend including frequency of therapy services in the Treatment Plan/CEPP.
  4. Pg. 36 (Third paragraph): “Health literacy counseling must be provided by a LMHP, LMHP-R, LMHP-RP, LMHP-S, Nurse Practitioner, Physician Assistant, CSAC*, CSAC Supervisee* or a RN or LPN with at least one year of clinical experience involving medication management.”
    1. Recommend including QMHP and QMHP trainee.
    2. Recommend removing the year of required experience for authorized nurses. It is already difficult finding nurses to hire without limiting the available pool of applicants.
  5. Pg. 36 (Admission Criteria, #2a)

“Individuals must meet all of the following criteria: … The individual is currently under a Temporary Detention Order;” and

pg. 37 (Exclusion Criteria, #3a)

“Any one of the following criteria is sufficient for exclusion from this level of care: … The individual does not voluntarily consent to admission with the following exceptions: 1. The individual has agreed at an involuntary commitment hearing to a voluntary placement within an RCSU and are ordered to remain for 72 hours and must provide 48 hours’ notice of intent to leave; or 2. The individual is committed through an involuntary commitment hearing to an involuntary placement within the RCSU”

    1. These two sections appear to contradict each other. A person can be admitted under a TDO. However, if they are not voluntary and have not had their commitment hearing, it is exclusionary. Recommend adding a third option to the Exclusionary Criteria exceptions, “The individual is under a Temporary Detention Order awaiting their hearing.”
  1. Pg. 33 (last bullet): “Services must be provided in-person with the exception of the psychiatric evaluation and care coordination.”
    1. The initial clinical assessment has been allowed to be completed via telehealth during the Public Health Emergency, with discussion of continuing to allow it following the cessation of the PHE. Recommend including this in the services that are allowed to be completed via telehealth. This would allow better use of scare resources, especially as there is difficulty in hiring sufficient numbers of LMHP’s (and residents/supervisees).
  2. Pg. 36 (9th paragraph): “RNs, LPNs, and Nurse Practitioners shall hold an active license issued by the Virginia Board of Nursing.”
    1. Virginia is a member of the interstate nursing compact, which should allow nurses from other states within the compact to work at the RCSU’s. Recommend adding to the end of that sentence “or from a state participating in the Interstate Nursing Compact.”
  3. Pg. 32 (3rd bullet)

“The Crisis Education and Prevention Plan (CEPP) meeting DBHDS requirements is required for this service and must be current. The CEPP process should be collaborative but must be directed and authorized by a LMHP, LMHP-R, LMHP-RP or LMHP-S.” and

Pg. 36 (first paragraph)

Treatment Planning must be provided by an LMHP, LMHP-R, LMHP-RP, LMHP-S; QMHP-A, QMHP-C, QMHP-E, CSAC* or CSAC Supervisee*.”

  1. Does the CEPP replace the Treatment Plan or is it in addition to it? Both are mentioned in these sections, and the staff who are qualified to complete them require different credentials. Recommend to clarify if the CEPP replaces the Treatment Plan or is in addition to it, and confirm the credentials of the staff who completes it.
  1. Pg. 35 (Staff Requirements, first paragraph): “Residential Crisis Stabilization Units must be staffed with a multi-disciplinary team of physicians, nurses, LMHPs, LMHP-Rs, LMHP-RPs, LMHP-Ss, QMHP-As, QMHP-Cs, QMHP-Es, CSACs CSAC-Supervisees, CSAC-As, RNs, LPNs and a registered peer recovery specialist. Residential aide level staff can also provide services and support under the supervision of an LMHP.”
    1. Are all mentioned providers required to be on staff, or select ones as appropriate to that unit? QMHP-Cs would not be appropriate for an adult program such as this. CSAC-A’s would have very limited capabilities. Recommend changing wording to “Residential Crisis Stabilization Units must be staffed with a multi-disciplinary team, to include as appropriate: physicians, nurses…”

 

CommentID: 116547
 

10/25/21  10:54 am
Commenter: Morgan Greer, MRCS

24/7 Nursing at CSU's
 

The original draft for CSU's did not require 24/7 nursing coverage and that requirement has been added to the newest draft. The requirement of 24/7 nursing at CSU's will make many CSU's across the state inoperable, especially only having 5 weeks notice to accommodate this requirement. Not only are CSBs facing workforce shortages in general, but there is a national nursing shortage which would make this an extremely difficult task to accomplish by Dec 1.

CommentID: 116557
 

10/25/21  11:00 am
Commenter: Morgan Greer, MRCS

CSU Psychiatric Evaluation Timeframe
 

Crisis stabilization has allowed up to 72 hours for a psychiatric evaluation and the updated requirement is at the time of admission. This will create a very overwhelming admission process for individuals where they will be assessed by an LMHP, nurse, and a psychiatrist/NP/PA while they're in the midst of a mental health crisis. Having up to 72 hours makes this much less taxing on the individuals that we serve. 

CommentID: 116558
 

10/26/21  10:42 am
Commenter: Joseph W Young, Jr., Board Chair NRVCSB

Detrimental changes to MH in Virginia!
 

The current proposed regulations place the existing Crisis Stabilization Units and growing Crisis Receiving Centers (23 hour observation) at risk by eliminating the ability for these critical programs to generate Medicaid revenue upon which they must rely for sustainability.  Of primary concern are the requirements that these programs have 24/7 Registered Nurse (RN) staffing at a time when the America Nursing Association has asked federal agencies to designate the nursing shortage in the US as a national emergency.  There simply are not enough RNs, particularly in rural areas of the state, to meet this need and to recruit these RNs, these services would potentially be pulling resources from our medical hospitals and providers who desperately need them due to the on-going pandemic and national state of emergency. Without the Crisis Stabilization Units in our communities many individuals will not be able to access the necessary care at a time when Virginia’s safety net, the state hospitals are unavailable due in part to the very workforce shortages that these programs will now face related to nursing.  A grace period of 9 to 12 months to meet the nursing requirements in these regulations or allowance to use Licensed Professional Nurses without an RN on site is a more reasonable expectation.

 Nursing assessment should not be required for either the 23 hour observation program nor the Residential Crisis Stabilization Unit.

 The requirement for preadmission screening services to be routed through the regional “Crisis Hotline” is in conflict with the Code of Virginia which requires law enforcement to contact the Community Services Board at the earliest possible time after executing an emergency custody order. This requirement is cumbersome at best and dangerous in creating barriers the Code changes of 2013 sought to overcome.

 The immediate access to psychiatrist or Nurse Practitioner to at the time of admission to both 23 hour observation and Residential Crisis Stabilization will a barrier to care as current availability of on-call psychiatrists and psychiatric Nurse Practitioners does not require assessment 24 hours per day.  Availability by phone should be sufficient.  A requirement for consumers to receive psychiatric evaluation as appropriate in the 23 hour observation service and within 24 hours of admission to Residential Crisis Stabilization Units is more appropriate.  Psychiatric medications will not always be a necessary component of 23 hour observation services and should not be a service requirement.

 These regulations threaten more than 42 acute beds in Region III of Virginia and many areas of Region III are HRSA designated mental health provider shortage areas.  The consequences to our communities will be devastating if enacted as presented.

CommentID: 116563
 

10/26/21  10:56 am
Commenter: Kristie Williams NRVCS

Medicaid Reg changes
 
CommentID: 116564
 

10/26/21  10:58 am
Commenter: Amy

Community Stab and RCSU authorization
 

Do the Community Stab/RSCU authorization, do they have to be submitted by the requested start date or they will be considered late?

Community Stab:

"The continued stay service authorization request must be submitted no earlier than 48 hours before the requested start date of the continued stay."

RCSU:

"If additional activities beyond 5 calendar days/5 units are clinically required, the provider shall submit an authorization request to the FFS contractor or MCO through a continued stay service authorization request accompanied by a CEPP submitted no earlier than 24 hours before the requested start date of the continued stay. " 

CommentID: 116565
 

10/26/21  3:05 pm
Commenter: Susan Richardson, NRVCS

Detrimental Medicaid Reg. Changes
 

The current proposed regulations place the existing Crisis Stabilization Units and growing Crisis Receiving Centers (23 hour observation) at risk by eliminating the ability for these critical programs to generate Medicaid revenue upon which they must rely for sustainability.  Of primary concern are the requirements that these programs have 24/7 Registered Nurse (RN) staffing at a time when the America Nursing Association has asked federal agencies to designate the nursing shortage in the US as a national emergency.  There simply are not enough RNs, particularly in rural areas of the state, to meet this need and to recruit these RNs, these services would potentially be pulling resources from our medical hospitals and providers who desperately need them due to the on-going pandemic and national state of emergency. Without the Crisis Stabilization Units in our communities many individuals will not be able to access the necessary care at a time when Virginia’s safety net, the state hospitals are unavailable due in part to the very workforce shortages that these programs will now face related to nursing.  A grace period of 9 to 12 months to meet the nursing requirements in these regulations or allowance to use Licensed Professional Nurses without an RN on site is a more reasonable expectation.

 

Nursing assessment should not be required for either the 23 hour observation program nor the Residential Crisis Stabilization Unit.

 

The requirement for preadmission screening services to be routed through the regional “Crisis Hotline” is in conflict with the Code of Virginia which requires law enforcement to contact the Community Services Board at the earliest possible time after executing an emergency custody order. This requirement is cumbersome at best and dangerous in creating barriers the Code changes of 2013 sought to overcome.

 

The immediate access to psychiatrist or Nurse Practitioner to at the time of admission to both 23 hour observation and Residential Crisis Stabilization will a barrier to care as current availability of on-call psychiatrists and psychiatric Nurse Practitioners does not require assessment 24 hours per day.  Availability by phone should be sufficient.  A requirement for consumers to receive psychiatric evaluation as appropriate in the 23 hour observation service and within 24 hours of admission to Residential Crisis Stabilization Units is more appropriate.  Psychiatric medications will not always be a necessary component of 23 hour observation services and should not be a service requirement.

 

These regulations threaten more than 42 acute beds in Region III of Virginia and many areas of Region III are HRSA designated mental health provider shortage areas.  The consequences to our communities will be devastating if enacted as presented.

CommentID: 116567
 

10/26/21  5:05 pm
Commenter: Sean Runyon

Medicaid Reg Feedback/Questions
 

Hello, Please see several questions below:

 

Pg 31 - At the start of services, a LMHP, LMHP-R, LMHP-RP or LMHP-S must conduct an assessment to determine the individual’s appropriateness for the service. The assessment requirement can be met by one of the following.

 

  • What is considered the “start of services?”  During the referral process? How do you all interpret this statement?

 

Pg 32 -  A psychiatric evaluation by a psychiatrist, nurse practitioner or physician assistant must be available at the time of admission into the service.

 

The question here is: must be available at the time of admission into the service.

  • This looks like a psychiatric evaluation MUST be completed at the time of admission.  It says, “available.”   Are we talking prior to admission or at admission? 

 

Pg 32 - The Crisis Education and Prevention Plan (CEPP) meeting DBHDS requirements is required for this service and must be current. The CEPP process should be collaborative but must be directed and authorized by a LMHP, LMHP-R, LMHP-RP or LMHP-S.

 

  • My agency uses a Safety & Wellness Plan that incorporates the elements of the CEPP.  Will that document suffice?  

 

Pg 33 - On the day of admission, at a minimum, RCSU providers must provide assessment, psychiatric evaluation and a nursing assessment.

 

  • Which assessments and by whom?  Can a psych assessment w/n 24 hrs suffice?  What about an med review w/ telephone order read back (TORB)?
  •  

Pg 34 - Services may not be provided in other locations outside of the licensed site. Services shall not be provided for the sole reason of providing temporary housing to an individual; if the individual meets other admission criteria and housing is an additional assessed need, this should be noted on the service authorization request to support continued coordination of resources for the individual.

 

  • Mostly an FYI on this b/c we sometimes get push back on this a lot from MCO's to deny service.

 

Pg 36 - Individuals must meet all of the following criteria: 1. Documentation indicates evidence that the individual meets criteria for a primary diagnosis consistent with the most recent version of the Diagnostic and Statistical Manual 2. One of the following must be present:

a. The individual is currently under a Temporary Detention Order; b. Abrupt and substantial changes in behavior noted by severe impairment or acute decompensation in functioning related to a behavioral health problem; c. Actual or potential danger to self or others as evidenced by: a. Suicidal thoughts or behaviors and/or recent self-injurious behavior with suicidal intent; or b. Homicidal ideation; or c. Command hallucinations or delusions d. Significant loss of impulse control that threatens the safety of the individual and/or others or their ability to take care of themselves; e. Significant inability to maintain basic care for oneself and to keep oneself safe in the community in an age appropriate manner that is not associated with Dementia; f. Substance intoxication with suicidal/homicidal ideation or inability to care for self.

 

  • My interpretation of this is that where admission criteria previously required 2 (of the 4) criteria to be present, there will only be 1 of the above, plus supporting documentation.  That would require the prescreen to be updated; my CSU Referral Form to be updated (approved by DBHDS); and several CSU forms. This criteria is pretty different. Thoughts?

 

Pg 38 – Just a crucial observation.  I see it will be complicated to justify Continued Stays.  The pt has to meet ALL 8 criteria, but only 1 for admission.  That said, I would wager that none of our detox pts will meet ALL of these 8 criteria for Continued Stay and will likely get denied after the initial 5 day PA.

 

Pg 39 - RCSU services are initially authorized through a registration process for 5 calendar days/5 units. Submission of registrations must be within 1 business day of admission.

 

  • I’m still looking for clarification on what constitutes a “business day” since every day is a business day for CSU.  Do we still have until 11:59pm the following business day?

 

Pg 39 - If additional activities beyond 5 calendar days/5 units are clinically required, the provider shall submit an authorization request to the FFS contractor or MCO through a continued stay service authorization request accompanied by a CEPP submitted no earlier than 24 hours before the requested start date of the continued stay.

 

  • Same question as earlier…Will the my agency Safety & Wellness Plan suffice for the CEPP?
  • The second question is, b/c of this timeframe, anyone who is admitted on Tuesday or Wednesday will now need a Continued Stay over the weekend.  We do not presently discharge over the weekend due to challenges with care coordination.  We will either now be losing money; just housing them; or have to change our model to discharge over the weekend.  This is a major programmatic barrier.

 

Pg. 39 - The day of discharge is not billable.

 

  • Is the day of admission definitely billable?

Thank you!

CommentID: 116568
 

10/27/21  12:39 pm
Commenter: Melissa G Shaw

Appendix G would create devastating consequences for our community.
 

The current proposed regulations place the existing Crisis Stabilization Units and growing Crisis Receiving Centers (23 hour observation) at risk by eliminating the ability for these critical programs to generate Medicaid revenue upon which they must rely for sustainability.  Of primary concern are the requirements that these programs have 24/7 Registered Nurse (RN) staffing at a time when the America Nursing Association has asked federal agencies to designate the nursing shortage in the US as a national emergency.  There simply are not enough RNs, particularly in rural areas of the state, to meet this need and to recruit these RNs, these services would potentially be pulling resources from our medical hospitals and providers who desperately need them due to the on-going pandemic and national state of emergency. Without the Crisis Stabilization Units in our communities many individuals will not be able to access the necessary care at a time when Virginia’s safety net, the state hospitals are unavailable due in part to the very workforce shortages that these programs will now face related to nursing.  A grace period of 9 to 12 months to meet the nursing requirements in these regulations or allowance to use Licensed Professional Nurses without an RN on site is a more reasonable expectation.

 

Nursing assessment should not be required for either the 23 hour observation program nor the Residential Crisis Stabilization Unit.

 

The requirement for preadmission screening services to be routed through the regional “Crisis Hotline” is in conflict with the Code of Virginia which requires law enforcement to contact the Community Services Board at the earliest possible time after executing an emergency custody order. This requirement is cumbersome at best and dangerous in creating barriers the Code changes of 2013 sought to overcome.

 

The immediate access to psychiatrist or Nurse Practitioner to at the time of admission to both 23 hour observation and Residential Crisis Stabilization will serve as a barrier to care as current availability of on-call psychiatrists and psychiatric Nurse Practitioners does not require assessment 24 hours per day.  Availability by phone should be sufficient.  A requirement for consumers to receive psychiatric evaluation as appropriate in the 23 hour observation service and within 24 hours of admission to Residential Crisis Stabilization Units is more appropriate.  Psychiatric medications will not always be a necessary component of 23 hour observation services and should not be a service requirement.

 

These regulations threaten more than 42 acute beds in Region III of Virginia and many areas of Region III are HRSA designated mental health provider shortage areas.  The consequences to our communities will be devastating if enacted as presented.

CommentID: 116571
 

10/27/21  2:47 pm
Commenter: Jonina Moskowitz, VB Dept. of Human Services

Appendix G Comments and Concerns
 

Please revise the definition of “psychiatric evaluation” as standard terminology is that psychiatric evaluation is a type of assessment, completed by a provider with specific credentials, vs. being the ongoing care of medication management services.

What will be the DBHDS license required to provide Mobile Crisis Response services?  Page 9 states “crisis stabilization,” however page 19 states that Community Stabilization will require a DBHDS license for “Crisis Stabilization” – will these both fall under the current non-residential crisis stabilization license?  Information provided by DBHDS on September 13, 2021 in their DBHDS Monthly Key Updates indicates that Mobile Crisis Response “will replace the current crisis intervention definition.” 

While the Crisis Hotline is critical referral source, direct referrals to Mobile Crisis Response should also be allowed, to allow for faster response and decrease the risk of bottlenecks at the Crisis Hotline.  Similarly, although page 15 states that “a referral from the Crisis Hotline is required” for Community Stabilization, page 14 describes the services as being one to support individual at any one of three points in the array of crisis services.  How will the referral process work?  More specifically, will providers of Mobile Crisis Response need to contact the Crisis Hotline to refer someone to Community Stabilization for the time between the initial service and entry to an established follow up?  Will providers of higher level of care services need to contact the Crisis Hotline to refer individuals for a transitional step-down?  This would seem to be inefficient and detracts from the role of the Crisis Hotline.

Thank you for adjusting the exclusion criteria to specify the exclusion of individuals who do not meet criteria and are attempting to use this solely as an alternative to incarceration.

Please postpone the additional requirement for Mobile Crisis Response and Community Stabilization to be provided 24 hours per day.  While this is our ideal, shared goal, notification of this requirement in mid-October does not provide adequate time to seek out and hire already scare resource for a December 1, 2021 implementation date. 

For Residential Crisis Stabilization, stating that staff must be available at the time of admission to provide a psychiatric evaluation and that psychiatric evaluations must occur on the day of admission is prohibitive.  Revise “on the day of” to a specified timeframe such as 24 hours, which affords services to be provided in a reasonable timeframe for individuals admitted at either 10:00 a.m. or at 10:00 p.m.  

Should the statement about a seven day overlap with other behavioral health services (p. 34) be an independent statement, vs. a bullet point?  As written, it is unclear if that is excluded from concurrent billing or an allowance that recognizes the importance of continuity of care.

Please postpone the additional requirement for an RN to be present on the unit at an RCSU 24/7 considering the current staff shortages faced by all health care providers.  Notification of this requirement in mid-October does not provide adequate time to seek out and hire an already scare resource for a December 1, 2021 implementation date.  Similarly, additional time is needed to allow currently employed Peer Recovery Specialists to complete the steps needed to become Registered in their field.

Previously articulated, significant, concerns that the funding for these services is not adequate to ensure that high caliber services, by qualified individuals, is able to be provided is magnified by the increased staffing requirements.  Ensure reimbursement rates adequately reflect the expense of providing this type of service.  Ensure the billing rules allow for a smooth flow and appropriate remuneration for providers of each service.  Similarly, to say that Residential Crisis Stabilization services are not billable on the day of discharge discounts the importance of services that are a part of the discharge process and their importance in successful transition.

Previously, there had been indications that the LOCUS would be implemented with these services suggesting as a focused and shorter means of assessing clinical status and needs.  This revision returned to use of the lengthy Comprehensive Needs Assessment or an unspecified DBHDS approved assessment.  Please ensure expectations include an assessment option that meets the needs without placing undue stress on individuals who crisis, who are often unable to participate in a lengthy assessment process.  In addition, there is a need for latitude in completing an assessment “at the start of services, “as there are instances in which direct intervention may help stabilize the situation more quickly than diving into a structured assessment.  While assessment is a critical aspect of service delivery, in a crisis, de-escalation should be the primary focus.

We again request that DMAS work with all six contracted MCOs to ensure consistency regarding the durations of initial service authorizations.  Having to negotiate and monitor different timeframes across multiple MCOs detracts from time devoted to service delivery and supervision of these critical services.

Ensure that requirements regarding Crisis Education and Prevention Plans are not overly constrictive or cumbersome and are reflective of current best practices and allowances.

CommentID: 116572
 

10/28/21  12:31 pm
Commenter: Amy Erb

RCSU/Psychiatric evaluation
 

Given challenges of maintaining psychiatry, NP or PA staff onsite 24/7, recommend that the standard for completion of a psychiatric evaluation be changed from "time of admission" to within 24 hours of admission with this level staff being available 24/7 for consultation. Overall, concerned about the substantial increase in expectations around all medical services while, at the same time, the overall maximum daily reimbursement rate is decreasing.  This, at a time when the limited supply of medical personnel are being pulled away from the public sector to the private, for-profit sector by rates of pay we cannot compete with.

CommentID: 116576
 

10/28/21  12:34 pm
Commenter: Amy Erb

RCSU/Nursing requirements
 

Please reconsider the requirement for 24-hr in person nursing given the nationwide nursing shortage. As well, consider the level of credentials nursing staff must hold to provide care in this setting. Many existing CSUs will not be able to operate beyond 12/1, if this goes into effect.

CommentID: 116577
 

10/29/21  1:41 pm
Commenter: Tamara Starnes

RCSU Psych eval
 

Existing regs: “DMAS recommends that an individual eligible for crisis stabilization services receive a psychiatric/medical evaluation within 72 hours of admission to the service.” Current CSUs are staffed to meet this reg. 

Many use a medical provider “rounding on the unit” several hours per day model, as a way to complete psych evals.  Most admissions have had a very recent psych eval, such as in an emergency department, and can wait for a full psych eval during daytime hours. 

Many CSUs cannot pivot to  provide “upon admission” by Dec 1s  and without significant cost increases, especially considering night and weekend coverage, and workforce shortages. 

Recommend: Not changing the current standard of 72 hours max.  Or, Align with ARTS Regs which would help with consistency in dual units: Psychiatric consultation provided within 24 hours of request; consultation and emergency coverage available 24/7.

Could further note Psychiatric evaluation within 72 hours max, or sooner if symptoms required, and consultation available 24/7. This would allow for quick medication reviews by phone, and full evals later. 

CommentID: 116578
 

10/29/21  1:46 pm
Commenter: Tamara Starnes

Peer Services
 

Regarding requirement for Peers to Register with the board. It is understood this is required to bill Medicaid. Can that be clarified in the regs? Reason is, many peers are not hired already certified or registered. To get there, they need time to get experience and training. Would like to be able to use peers in CSUs for example, while they are in the process of getting to certification and registration. 

CommentID: 116579
 

10/29/21  3:29 pm
Commenter: anonymous

Mobile crisis
 

Mobile crisis must be 24/7 - this could keep new services from forming. Would rather be able to offer some hours, versus no hours, especially as programs are building up staffing coverage. 

CommentID: 116580
 

11/1/21  4:22 pm
Commenter: Mac Babb

General observations on proposed regulations
 

In consultation with local mental health professionals and after reviewing proposed documents, it appears that some of the regulations have potential outcomes that may negatively impact regions of Virginia. 

Key areas of concern include:

-The proposed regulations potentially create obstacles for local resources to bill for certain services which impacts their funding.  Reduced funding (or access to funds) equals reduced services available to the community. 

-It has been suggested that the proposed regulations may result in the reduction of available bed space for certain regions.  Under no circumstance should the implementation of regulations result in the loss of bed space for consumers of mental health services.  There is a current shortage which should not be knowingly exacerbated.

-The requirement of having on-site RN's 24/7 may force existing crisis centers/stabilization units with medical plans to reduce hours of operation if they cannot fill staffing requirements.  Forward progress in mental health should not be at the expense of existing services.  

I would encourage this regulatory body to work closely with Community Service Boards and stakeholder groups within all of the regions to determine the actual, negative consequences of imposing these regulations and mitigate them prior to implementation.  Virginia is in a very delicate moment with its decisions about mental health.  We should not take steps forward if there is information existing that suggests we will negatively impact our citizens in the process. 

CommentID: 116591
 

11/1/21  4:58 pm
Commenter: Cumberland Mountain CSB

Mobile Crisis Response/Required activities/Referral from Crisis Hotline
 

This service can occur when there is an ECO.  LEO will not contact a crisis hotline for this referral as this is contrary to processes which have been in place for many years and allows for miscommunication, unnecessary delays in the process. There are indications that the "referral" to the crisis hotline can occur after the service has begun/occurred.  Language and process are not clear.  

CommentID: 116593
 

11/1/21  5:01 pm
Commenter: Cumberland Mountain CSB

Community Crisis Stab/crisis hotline referral
 

Requirement of crisis hotline referral as a for billing does not allow consumers to transition between levels of crisis care smoothly based on need.  For example, it is not reasonable for a person served in 23 hour crisis observation to require a separate crisis hotline call to be referred for community crisis stabilization.  Nor would it be reasonable to call the crisis hotline to transition an individual from 23 hour crisis observation to residential crisis stabilization services that are co-located. 

CommentID: 116594
 

11/1/21  5:10 pm
Commenter: Cumberland Mountain CSB

23 hour CS/Psych eval provider qualifications/psych eval at admission
 

Page 24 of the draft manual states that "A psychiatric evaluation by a psychiatrist, nurse practitioner or physician assistant must be available at the time of admission into that service."   Page 27 then states that "A licensed psychiatrist of psychiatric nurse practitioner (who is acting within the scope of their professional license and applicable state law) must be available to the program 24/7 either in person or via telemedicine to provide assessment, treatment recommendations and consultation." Is a PA acceptable or not? Is an NP who is not a psychiatric certified NP acceptable or not?  Concerning as there is a limited supply of providers across the state and psychiatric certified NPs are rare.  Additionally, not all individuals who enter 23 hour CS are in need of a psych eval/prescribed medications as this is not clinically indicated or appropriate.  This should only be required following a clinical assessment by an LMHP that indicates need for such psych eval.  

CommentID: 116595
 

11/1/21  5:15 pm
Commenter: Cumberland Mountain CSB

23 Hour CS: 24/7 RN requirement
 

The requirement for an RN 24/7 appears to be unnecessary; however, having 24/7 accessibility to an RN or NP to provide supervision to LPN staff or respond on site as needed would seem reasonable.  Otherwise, if an on-site RN is required 24/7, there is no need for LPN staff on site.   Earlier draft regulations did not appear to require 24/7 RN staffing (August 2021).  

CommentID: 116596
 

11/1/21  5:27 pm
Commenter: Cumberland Mountain CSB

RCSU/Psych Eval provider qualifications
 

Pg. 32 indicates that a pscyh eval can be done by psychiatrist, NP or PA.  Pg. 35 states that the psych eval is to be done by a psychiatrist or psychiatric NP and meet the licensing standards for residential crisis stab and medically monitored withdrawal services at ASAM 3.5 and 3.7. Is a PA acceptable?  Is an NP who is not psych certified acceptable?  For co-occurring enhanced programs providing ASAM 3.7, the ARTs manual (p. 57) requires a psychiatric assessment within 4 hours of admission by telephone and within 24 hours following admission in person or via telemedicine, or soon as appropriate or medically necessary.  P. 54 of the ARTS manual requires an addiction-credentialed physician or physician with experience in addiction medicine  to oversee the treatment process and ensure quality of care, while licensed physicians or physician extenders are required to complete a physical exam of the person within 24 hours of admission.  Language is contradictory regarding who is qualified to complete necessary psych eval/admission eval.

 

CommentID: 116598
 

11/1/21  5:45 pm
Commenter: Cumberland Mountain CSB

RCSU/Assessment Requirements
 

Pg. 31 says an LMHP must conduct an assessment at the "start of services."  Pg. 32 says the psych eval must be "available at the time of admission" and that a nursing assessment is to occur "upon admission."  Pg. 33 states that "On the day of admission, at a minimum, RCSU providers must provide assessment, psychiatric evaluation and a nursing assessment."  Currently, in RCSU, the psych eval is to occur w/in 72 hours of admission.  So, are all three of these assessments due at the start of services, at the time of admission, or upon admission?  Is admission defined the moment the person enters the RCSU? Is the admission considered a process that occurs over a 24 hour period given the nature of the RCSU?  Individuals are admitted to RCSU 24/7.  Many are admitted during the late night, early morning hours, via TDO and following prolonged stays in emergency rooms, etc.  None of these required assessments are brief.  It seems that we are creating a situation that is not person-centered and further adds to individual's trauma by bombarding them with 3 assessments "at the time of admission."  Individuals who arrive to the RCSU under the influence of alcohol or drugs are often times incapable of walking in the door and completing this level of continuous assessment.  

 

CommentID: 116599
 

11/1/21  5:50 pm
Commenter: Cumberland Mountain CSB

RCSU: 24/7 RN present on the unit
 

The requirement for 24/7 RN coverage appears to be unnecessary and it would appear that having LPNs on-site who have access to an RN/NP at all times would be acceptable.  If an RN is to be on-site at all times, the use of LPNs will not be useful or feasible.

CommentID: 116600
 

11/1/21  5:55 pm
Commenter: Cumberland Mountain CSB

RCSU: initial registration 5 days
 

Will this 5 day initial registration be consistent across all MCOs for this services as, currently, there is no consistency amongst initial period of authorization for the MCOs nor have the MCOs adhered to the defined initial authorizations currently in place?

CommentID: 116601
 

11/1/21  5:59 pm
Commenter: Cumberland Mountain CSB

CEPP
 

The CEPP is required for multiple services.  The CEPP is a lengthy document and seems unnecessary for acute, shorter term services.  Given the arduous assessment process and the CEPP, it would seem the staff will be spending more time documenting than providing direct care which is not person-centered nor does it speak to the spirit of Project Bravo.

CommentID: 116602
 

11/1/21  6:07 pm
Commenter: Cumberland Mountain CSB

RCSU: language regarding involuntary admission
 

While the billing codes in this section identify RCSU billing for TDOs, the language around involuntary individuals does not and appears contradictory.  The individual being under a TDO meets medical necessity criteria, but the description under which individual who are involuntary may receive the service indicates only individuals on voluntary or involuntary commitment may be billed for.  Suggest language added under exceptions to include "Individual is under a TDO awaiting hearing."

CommentID: 116603
 

11/2/21  10:39 am
Commenter: Brandon Rodgers, Western Tidewater CSB

Residential Crisis Stabilization 24/7 Nursing and RN Oversight
 

In regards to Page 27 (23 Hour Observation) and Page 35 (Residential Crisis Stabilization) there are staffing requirements for an RN to be onsite supervising an LPN at all times.  While it is indeed best practice, given workforce shortages across the Commonwealth it is unrealistic to ensure onsite coverage by an RN 24/7 and likely would decrease the availability of qualified providers.  In light of this, an LPN practicing onsite may have capacity to reach an on call RN, NP, PA, or MD for clinical guidance.

In regards to Page 32 (Residential Crisis Stabilization) the requirement of 24/7 nursing, while best practice again is at risk of disqualifying providers during the current pandemic related workforce shortage.  Alternatively medication technicians trained in an approved course by DBHDS could assist with medication administration and nursing services be available on call or as needed for the level of care of individuals on the unit until staffing levels can stabilize post pandemic.

CommentID: 116605
 

11/2/21  10:45 am
Commenter: Brandon Rodgers, Western Tidewater CSB

Referral from the Crisis Hotline
 

On page 7 (Mobile Crisis Response) the requirement of a referral from the Crisis Hotline is required.  It is noted that collaboration and service coordinated with the Crisis Hotline is best practice for the crisis continuum.  However; the Crisis Hotline remains developmental and at the start of these regulations it is likely will not be fully capable of addressing this requirement and potentially limiting provider capacity to seek reimbursement for necessary services to promote community stabilization and decrease acute hospitalization.

Consider revised wording to read as coordination with a Regional Crisis Call Center, and potentially consider a grace period of 6-12 months to ensure that provider capacity and coordination with the developmental call centers does not negatively impact the availability of care to members.

CommentID: 116606
 

11/2/21  8:07 pm
Commenter: Kim Woodlee, MRCS

24/7 RN Coverage
 

For the ARCSU, it is concerning that the expectation will be 24/7 RN coverage or LPN with RN on site.   Our adult CSU currently utilizes LPNs on night shift only and they have access to an RN via phone throughout their shift.   LPNs were hired due to our inability to obtain RNs at the point in time of hire.   If we were unable to utilize those LPNs with RN available via phone, I feel certain that we would not be able to provide 24/7 nursing care in that facility.   

CommentID: 116607
 

11/2/21  8:28 pm
Commenter: Kim Woodlee, MRCS

Referral from Crisis Hotline for Mobile Crisis Services
 

The requirement of a referral from the crisis hotline for mobile crisis is problematic in that it creates a barrier to an already established service and process within our agency and community.   Our team has gone to great lengths to develop positive relationships within our communities and our local schools, physicians, law enforcement, and other community partners regularly reach out personally to our team in an effort to provide timely, on-site interventions and to ultimately avoid unnecessary hospitalizations.   Personal relationships with our team has been the driving force within our small communities and calling a hotline for assistance does not provide the same response as a local, known entity.   

CommentID: 116608
 

11/2/21  8:53 pm
Commenter: Kim Woodlee, MRCS

Definition needed for "at time of admission" for CSU
 

CSU Admissions - Please change "at time of admission" to "within 24 hours" in relation to when assessments need to be completed.   Vague terminology can lead to varying interpretations by MCOs.   In addition, three assessments completed at time of admission can be difficult to accomplish given that individuals are in crisis and have most likely already been through an assessment prior to arriving.       

CommentID: 116609
 

11/3/21  9:44 am
Commenter: Shenee McCray, RBHA

Comprehensive Crisis Services
 

Mobile Crisis Response

The draft manual indicates that a referral from the Crisis Hotline is required.  It is recommended that this requirement be removed as it eliminates the notion of “no wrong door”.  Many crisis referrals come from many places such as the hospital ED, schools, emergency services, etc.  This requirement would significantly increase the call volume for the regional call centers unnecessarily so.  This requirement would also add another step for the person in crisis or the referring entity.

On page 10, the 7th bullet indicates that “Peer Recovery Support Services must be provided by a Registered Peer Recovery Specialist”.  What is the timeframe in which the peer should become registered?

 

Community Stabilization

The draft manual indicates that a referral from the Crisis Hotline is required.  It is recommended that this requirement be removed as it eliminates the notion of “no wrong door”.  Many crisis referrals come from many places such as the hospital ED, schools, emergency services, etc.  This requirement would significantly increase the call volume for the regional call centers unnecessarily so.  This requirement would also add another step for the person in crisis or the referring entity.

On page 16, the 4th bullet indicates that CEPPs must be reviewed and updated as an individual moves between crisis services (Mobile Crisis Response, Community Stabilization, Residential Crisis Stabilization unit, 23-hour Crisis Stabilization) according to DBHDS requirements. Please provide clarity as the CEPP is not required for Mobile Crisis Response (and shouldn’t be required) however it is listed here as if it is required.

 

Residential Crisis Stabilization

On page 32, the first bullet indicates that “a psychiatric evaluation by a psychiatrist, nurse practitioner or physician assistant must be available at the time of admission into the service”  It is recommended that a psychiatric evaluation is be required within 24-48 hours of admission.  Many programs do not have a prescriber available at the time of admission.

On page 39, #4 under Residential Crisis Stabilization Billing Requirements, it says “If a provider is licensed for both RCSU and for the provision of ASAM Level3.5 and/or 3.7 – WM, and an individual is admitted to the RCSU for withdrawal management services, the provider should bill for the Addiction and Recovery Treatment Services until withdrawal management is no longer needed.  At that time they may submit a registration for RCSU services.”  It is recommended withdrawal management be allowed as an option for this service as long as there is sufficient documentation to support withdrawal management services.

CommentID: 116610
 

11/3/21  6:50 pm
Commenter: Sandra L Irby

Crisis Services
 

Mobile Crisis Response

Crisis Hotline Requirement:

The requirement to receive the referral from the Crisis Hotline to obtain payment for work performed is a concern.  Referrals for crisis services come from various avenues (law enforcement/emergency room/private providers/self-referrals, 24 hour emergency services line, etc.).  Self-referrals are received from individuals showing up at the door indicating a crisis.  It seems that the requirement for a referral to come from the crisis hotline is an added step that hinders positive customer service and hinders the staff by taking away from the customer who needs the service immediately.  There are organically occurring referrals in crisis. 

Questions:  The crisis services and the crisis transformation relies heavily on the positive interaction among community partners.  When law enforcement or other community partners must go through a regional crisis hotline in order to access a service, it is concerning that these relationships will be burdened with a third party contact.  Who is responsible for making these calls to the crisis hotline?  What is the purpose of calling the hotline to utilize a service that the CSB has always performed/provided?  In addition, the Code of Virginia states that law enforcement agencies are to notify the CSB of an executed Emergency Custody Order.  It is concerning that the requirement to receive a referral from the crisis hotline would create room for error and delayed time.  These calls should come directly to the CSB.  If the purpose of the requirement is to collect data, the regulations should spell out the expectation is to contact the crisis hotline to log a contact, not receive a referral and payment for a service.

 

Mobile Crisis Response Assessment:

The draft of the Medicaid manual does not clarify what kind of assessment is acceptable.  Since a preadmission screening is a service that can be provided under the mobile crisis service, it would be suggested that the prescreen be a tool to use for the mobile crisis assessment.  A determination would need to be made as to whether or not an individual needed involuntary psychiatric hospitalization or not in the midst of the crisis. When the individual does not meet involuntary hospitalization criteria, then the prescreen could be used as a mechanism to begin for mobile crisis response/services.

 

Staff requirements to complete a pre-admission screening:

The requirement of an LMHP or LMHP eligible staff person to complete the pre-screening will have a negative impact on the workforce in some areas of the state.  Requiring a LMHP to be available in real time with a QMHP to complete a prescreening is a waste of resources.  Prescreeners were grandfathered or have been conducting pre-admission screenings for many years.  To say that they are no longer able to bill for a service that has been performed for years by a particular staff solely based on their credentials effective December 1 does not make sense and will be detrimental to the community due to reduced workforce staffing.  A staff person certified by DBHDS should have the ability to bill for the service.  The CSB is the backbone of crisis services in the community and employs good clinicians to provide the services. There is no reason why a DBHDS prescreener could not provide preadmission screening or mobile crisis services.  In fact, a prescreener would have more clinical training than a CSAC or QMHP would have to respond to crisis situations.  The prescreening service should be pulled out from mobile crisis and billed as a separate service item to reduce confusion.

 

Community Crisis Stabilization

Requirement of crisis hotline referral as a condition of billing does not allow for consumers to transition between levels of crisis care smoothly based on need – for example it is not reasonable for a consumer served in 23 hour crisis observation to require a separate crisis hotline call to be referred for community crisis stabilization

The assessment for Crisis Stabilization is not defined as to what would be acceptable as the third option to enter the service.

If it is expected that a CEPP be used for the crisis services, what does this look like?  REACH has a CEPP and it is lengthy.  This is a concern as to time spent documenting when essential services can be provided to the individual who is in crisis.

 

23- Hour Crisis Stabilization

                Psychiatric evaluation requirement: 

Regulations states psychiatric evaluation must be available at the time of admission which is inappropriate clinically and should only be required when assessed by the LMHP type to be necessary.  Not all consumers will require psychiatric evaluation and prescribing of medication during this service.

Unable to occur due to workforce shortages there are simply not funds to pay for nor psychiatrist/ psychiatric nurse practitioners available to provide this service 24 hours per day

 

24/7 Registered Nurse Requirement:

The U.S. is in the midst of a pandemic and well documented nursing crisis.  The requirement for 24 Registered Nurse (RN) coverage is unnecessary and staffing to support this is unavailable in the current workforce.

The allowance for use of a Licensed Practical Nurse is unhelpful because it requires an RN to be at the facility. 

If nursing is a required component it should be on an as needed basis- available to respond to the location OR allow for LPN level nursing with access to an RN by phone for oversight/ supervision.

This requirement is cost prohibitive and cannot be accomplished by providers with a December 1, 2021 implementation date.

Earlier draft of regulations did not require 24/7 RN staffing, including those draft regulations circulated by DMAS in August 2021.

There is contradictory language about who can provide assessment: In some sections it indicates Physician Assistants can provide care and then later allows only psychiatrist or psychiatric Nurse Practitioner to provide care.

 

Other concerns

                Assessment- 23 hour & CSU level

References to multiple assessments that may be used/ required.  Assessment should be consistent with other services and utilize the Comprehensive Needs Assessment for this purpose without creating additional assessments that will require consumers to repeat their stories and are redundant.

Assessment should align with the CNA requirements for ARTS so that two separate assessments are not required.

 

Crisis Education and Prevention Plan

Required for multiple services.  This is unnecessary, particularly in more acute, shorter term services such as stabilization and 23 hour observation- Current CEPP used by REACH is excessively cumbersome.

 

 

 

 

 

 

CommentID: 116613
 

11/4/21  9:32 am
Commenter: Jodie Burton

Mental Health Services Manual
 

 

Mobile Crisis Response

Crisis Hotline Requirement:

The requirement to receive the referral from the Crisis Hotline to obtain payment for work performed is a concern.  Referrals for crisis services come from various avenues (law enforcement/emergency room/private providers/self-referrals, 24 hour emergency services line, etc.).  Self-referrals are received from individuals showing up at the door indicating a crisis.  It seems that the requirement for a referral to come from the crisis hotline is an added step that hinders positive customer service and hinders the staff by taking away from the customer who needs the service immediately.  There are organically occurring referrals in crisis. 

Questions:  The crisis services and the crisis transformation relies heavily on the positive interaction among community partners.  When law enforcement or other community partners must go through a regional crisis hotline in order to access a service, it is concerning that these relationships will be burdened with a third party contact.  Who is responsible for making these calls to the crisis hotline?  What is the purpose of calling the hotline to utilize a service that the CSB has always performed/provided?  In addition, the Code of Virginia states that law enforcement agencies are to notify the CSB of an executed Emergency Custody Order.  It is concerning that the requirement to receive a referral from the crisis hotline would create room for error and delayed time.  These calls should come directly to the CSB.  If the purpose of the requirement is to collect data, the regulations should spell out the expectation is to contact the crisis hotline to log a contact, not receive a referral and payment for a service.

 

Mobile Crisis Response Assessment:

The draft of the Medicaid manual does not clarify what kind of assessment is acceptable.  Since a preadmission screening is a service that can be provided under the mobile crisis service, it would be suggested that the prescreen be a tool to use for the mobile crisis assessment.  A determination would need to be made as to whether or not an individual needed involuntary psychiatric hospitalization or not in the midst of the crisis. When the individual does not meet involuntary hospitalization criteria, then the prescreen could be used as a mechanism to begin for mobile crisis response/services.

 

Staff requirements to complete a pre-admission screening:

The requirement of an LMHP or LMHP eligible staff person to complete the pre-screening will have a negative impact on the workforce in some areas of the state.  Requiring a LMHP to be available in real time with a QMHP to complete a prescreening is a waste of resources.  Prescreeners were grandfathered or have been conducting pre-admission screenings for many years.  To say that they are no longer able to bill for a service that has been performed for years by a particular staff solely based on their credentials effective December 1 does not make sense and will be detrimental to the community due to reduced workforce staffing.  A staff person certified by DBHDS should have the ability to bill for the service.  The CSB is the backbone of crisis services in the community and employs good clinicians to provide the services. There is no reason why a DBHDS prescreener could not provide preadmission screening or mobile crisis services.  In fact, a prescreener would have more clinical training than a CSAC or QMHP would have to respond to crisis situations.  The prescreening service should be pulled out from mobile crisis and billed as a separate service item to reduce confusion.

 

Community Crisis Stabilization

Requirement of crisis hotline referral as a condition of billing does not allow for consumers to transition between levels of crisis care smoothly based on need – for example it is not reasonable for a consumer served in 23 hour crisis observation to require a separate crisis hotline call to be referred for community crisis stabilization

The assessment for Crisis Stabilization is not defined as to what would be acceptable as the third option to enter the service.

If it is expected that a CEPP be used for the crisis services, what does this look like?  REACH has a CEPP and it is lengthy.  This is a concern as to time spent documenting when essential services can be provided to the individual who is in crisis.

 

23- Hour Crisis Stabilization

                Psychiatric evaluation requirement: 

Regulations states psychiatric evaluation must be available at the time of admission which is inappropriate clinically and should only be required when assessed by the LMHP type to be necessary.  Not all consumers will require psychiatric evaluation and prescribing of medication during this service.

Unable to occur due to workforce shortages there are simply not funds to pay for nor psychiatrist/ psychiatric nurse practitioners available to provide this service 24 hours per day

 

24/7 Registered Nurse Requirement:

The U.S. is in the midst of a pandemic and well documented nursing crisis.  The requirement for 24 Registered Nurse (RN) coverage is unnecessary and staffing to support this is unavailable in the current workforce.

The allowance for use of a Licensed Practical Nurse is unhelpful because it requires an RN to be at the facility. 

If nursing is a required component it should be on an as needed basis- available to respond to the location OR allow for LPN level nursing with access to an RN by phone for oversight/ supervision.

This requirement is cost prohibitive and cannot be accomplished by providers with a December 1, 2021 implementation date.

Earlier draft of regulations did not require 24/7 RN staffing, including those draft regulations circulated by DMAS in August 2021.

There is contradictory language about who can provide assessment: In some sections it indicates Physician Assistants can provide care and then later allows only psychiatrist or psychiatric Nurse Practitioner to provide care.

 

Other concerns

                Assessment- 23 hour & CSU level

References to multiple assessments that may be used/ required.  Assessment should be consistent with other services and utilize the Comprehensive Needs Assessment for this purpose without creating additional assessments that will require consumers to repeat their stories and are redundant.

Assessment should align with the CNA requirements for ARTS so that two separate assessments are not required.

 

Crisis Education and Prevention Plan

Required for multiple services.  This is unnecessary, particularly in more acute, shorter term services such as stabilization and 23 hour observation- Current CEPP used by REACH is excessively cumbersome.

CommentID: 116614
 

11/4/21  11:23 am
Commenter: KJ Holbrook, MRCS

Impact of regulation changes and timeframe
 

Given we have a 12/1 start date to implement changes that involve:

  • Call centers that are not yet operational.
  • A crisis assessment tool that has not been formalized so providers may prepare for implementation (which requires training and EHR integration).
  • A CEPP that is required, but again, not formalized so providers may prepare for implementation.
  • A multitude of CPT changes which could change at the time of the final regs being released maybe 3 weeks prior to 12/1 (which again, requires significant work on the EHR end of things).
  • Several critical questions have been asked at last week's webex's that will inform agencies of process, needs, documentation, etc. and we are awaiting the FAQ's.

Taking these things into consideration, I believe many would appreciate a grace period for "going live" until these details are formalized and a reasonable time to establish and train on new processes as well as manage the data, billing, and EHR documentation changes required as a result.

I also have some concern that the 23hr model indicates we will only be able to bill one day for that service, yet there is a code for billing at TDO day which typically spans more than one day. Does this mean we will not be reimbursed if someone stays in the 23hr model more than one day, despite the fact that we have an order in place for them to be there?

The crisis/psych/nursing assessment all being required at time of admission or day of admission- the wording isn't clear what that expectation is and while I appreciate the effort shared in providing some allowances by doing that, establishing a time frame that will allow someone to be admitted and flow through acclimating to the center and sharing their story in a trauma informed way would be preferable.

I'd like to comment that for community crisis stabilization, "convenient and appropriate setting" could end up being an agency site. We work with individuals who live in tents or have hostile and destabilizing home environments at times and being reassured that we have the ability to work with them on stabilization in those environments would be appreciated.

I also agree with statements related to the nursing issues and the crisis hotline requirements.

CommentID: 116615
 

11/4/21  12:05 pm
Commenter: Scott Moye, Giles County Sheriff's Office

RN Requirement and Crisis Hotline
 

The requirement to staff a registered nurse will negatively impact law enforcement in a time where beds are already nearly impossible to find.  Our CSB has done a great job with finding solutions to the current problems we are facing and has done all it can to take some of the burden off of law enforcement officers.  This requirement will essentially end the progress we have made.  At this time, everyone is understaffed.  Hospitals, law enforcement agencies, crisis workers, and other frontline professions are struggling to find help.  It isn't because they aren't trying, people just aren't coming through the doors looking for work.  It is extremely unlikely that RNs can be found prior to these guidelines becoming mandated.

The regional crisis hotline will be just another turn off course in the disaster that our law enforcement officers have been facing with mental health efficiency now for years.  We have a good relationship with our existing emergency crisis workers and we have worked together to tackle the challenges of the extremely difficult landscape we find ourselves in today.  To add another element to the process of screening will further delay what seems to have become the inevitable answer at the end of an 8 hour period, no bed space.

There have been many recent attempts to overhaul the mental health system in Virginia.  Sadly, today we find it in the worst shape that I have seen it in during my 19 year career.  The answer seems to have always been more regulation without funding.  Law enforcement is strapped to the maximum for manpower right now.  I know that everyone involved here probably is too.  At the end of the day, it seems that we have very little say as stakeholders in this process.  Listen to your stakeholders and find long-term solutions to the problems we are facing.  That starts with better funding for all involved.

CommentID: 116617
 

11/4/21  12:23 pm
Commenter: Melanie Tosh

Crisis Services
 

Mobile Crisis Response

Crisis Hotline Requirement:

The requirement to receive the referral from the Crisis Hotline to obtain payment for work performed is a concern.  Referrals for crisis services come from various avenues (law enforcement/emergency room/private providers/self-referrals, 24 hour emergency services line, etc.).  Self-referrals are received from individuals showing up at the door indicating a crisis.  It seems that the requirement for a referral to come from the crisis hotline is an added step that hinders positive customer service and hinders the staff by taking away from the customer who needs the service immediately.  There are organically occurring referrals in crisis. 

Questions:  The crisis services and the crisis transformation relies heavily on the positive interaction among community partners.  When law enforcement or other community partners must go through a regional crisis hotline in order to access a service, it is concerning that these relationships will be burdened with a third party contact.  Who is responsible for making these calls to the crisis hotline?  What is the purpose of calling the hotline to utilize a service that the CSB has always performed/provided?  In addition, the Code of Virginia states that law enforcement agencies are to notify the CSB of an executed Emergency Custody Order.  It is concerning that the requirement to receive a referral from the crisis hotline would create room for error and delayed time.  These calls should come directly to the CSB.  If the purpose of the requirement is to collect data, the regulations should spell out the expectation is to contact the crisis hotline to log a contact, not receive a referral and payment for a service.

 

Mobile Crisis Response Assessment:

The draft of the Medicaid manual does not clarify what kind of assessment is acceptable.  Since a preadmission screening is a service that can be provided under the mobile crisis service, it would be suggested that the prescreen be a tool to use for the mobile crisis assessment.  A determination would need to be made as to whether or not an individual needed involuntary psychiatric hospitalization or not in the midst of the crisis. When the individual does not meet involuntary hospitalization criteria, then the prescreen could be used as a mechanism to begin for mobile crisis response/services.

 

Staff requirements to complete a pre-admission screening:

The requirement of an LMHP or LMHP eligible staff person to complete the pre-screening will have a negative impact on the workforce in some areas of the state.  Requiring a LMHP to be available in real time with a QMHP to complete a prescreening is a waste of resources.  Prescreeners were grandfathered or have been conducting pre-admission screenings for many years.  To say that they are no longer able to bill for a service that has been performed for years by a particular staff solely based on their credentials effective December 1 does not make sense and will be detrimental to the community due to reduced workforce staffing.  A staff person certified by DBHDS should have the ability to bill for the service.  The CSB is the backbone of crisis services in the community and employs good clinicians to provide the services. There is no reason why a DBHDS prescreener could not provide preadmission screening or mobile crisis services.  In fact, a prescreener would have more clinical training than a CSAC or QMHP would have to respond to crisis situations.  The prescreening service should be pulled out from mobile crisis and billed as a separate service item to reduce confusion.

 

Community Crisis Stabilization

Requirement of crisis hotline referral as a condition of billing does not allow for consumers to transition between levels of crisis care smoothly based on need – for example it is not reasonable for a consumer served in 23 hour crisis observation to require a separate crisis hotline call to be referred for community crisis stabilization

The assessment for Crisis Stabilization is not defined as to what would be acceptable as the third option to enter the service.

If it is expected that a CEPP be used for the crisis services, what does this look like?  REACH has a CEPP and it is lengthy.  This is a concern as to time spent documenting when essential services can be provided to the individual who is in crisis.

 

23- Hour Crisis Stabilization

                Psychiatric evaluation requirement: 

Regulations states psychiatric evaluation must be available at the time of admission which is inappropriate clinically and should only be required when assessed by the LMHP type to be necessary.  Not all consumers will require psychiatric evaluation and prescribing of medication during this service.

Unable to occur due to workforce shortages there are simply not funds to pay for nor psychiatrist/ psychiatric nurse practitioners available to provide this service 24 hours per day

 

24/7 Registered Nurse Requirement:

The U.S. is in the midst of a pandemic and well documented nursing crisis.  The requirement for 24 Registered Nurse (RN) coverage is unnecessary and staffing to support this is unavailable in the current workforce.

The allowance for use of a Licensed Practical Nurse is unhelpful because it requires an RN to be at the facility. 

If nursing is a required component it should be on an as needed basis- available to respond to the location OR allow for LPN level nursing with access to an RN by phone for oversight/ supervision.

This requirement is cost prohibitive and cannot be accomplished by providers with a December 1, 2021 implementation date.

Earlier draft of regulations did not require 24/7 RN staffing, including those draft regulations circulated by DMAS in August 2021.

There is contradictory language about who can provide assessment: In some sections it indicates Physician Assistants can provide care and then later allows only psychiatrist or psychiatric Nurse Practitioner to provide care.

 

Other concerns

                Assessment- 23 hour & CSU level

References to multiple assessments that may be used/ required.  Assessment should be consistent with other services and utilize the Comprehensive Needs Assessment for this purpose without creating additional assessments that will require consumers to repeat their stories and are redundant.

Assessment should align with the CNA requirements for ARTS so that two separate assessments are not required.

 

Crisis Education and Prevention Plan

Required for multiple services.  This is unnecessary, particularly in more acute, shorter term services such as stabilization and 23 hour observation- Current CEPP used by REACH is excessively cumbersome.

CommentID: 116618
 

11/4/21  1:02 pm
Commenter: Lauren Cressell

Crisis Services Comments
 

Public comment notes:

Mobile Crisis Response

Crisis Hotline Requirement:

The requirement to receive the referral from the Crisis Hotline to obtain payment for work performed is a concern.  Referrals for crisis services come from various avenues (law enforcement/emergency room/private providers/self-referrals, 24 hour emergency services line, etc.).  Self-referrals are received from individuals showing up at the door indicating a crisis.  It seems that the requirement for a referral to come from the crisis hotline is an added step that hinders positive customer service and hinders the staff by taking away from the customer who needs the service immediately.  There are organically occurring referrals in crisis. 

Questions:  The crisis services and the crisis transformation relies heavily on the positive interaction among community partners.  When law enforcement or other community partners must go through a regional crisis hotline in order to access a service, it is concerning that these relationships will be burdened with a third party contact.  Who is responsible for making these calls to the crisis hotline?  What is the purpose of calling the hotline to utilize a service that the CSB has always performed/provided?  In addition, the Code of Virginia states that law enforcement agencies are to notify the CSB of an executed Emergency Custody Order.  It is concerning that the requirement to receive a referral from the crisis hotline would create room for error and delayed time.  These calls should come directly to the CSB.  If the purpose of the requirement is to collect data, the regulations should spell out the expectation is to contact the crisis hotline to log a contact, not receive a referral and payment for a service.

 

Mobile Crisis Response Assessment:

The draft of the Medicaid manual does not clarify what kind of assessment is acceptable.  Since a preadmission screening is a service that can be provided under the mobile crisis service, it would be suggested that the prescreen be a tool to use for the mobile crisis assessment.  A determination would need to be made as to whether or not an individual needed involuntary psychiatric hospitalization or not in the midst of the crisis. When the individual does not meet involuntary hospitalization criteria, then the prescreen could be used as a mechanism to begin for mobile crisis response/services.

 

Staff requirements to complete a pre-admission screening:

The requirement of an LMHP or LMHP eligible staff person to complete the pre-screening will have a negative impact on the workforce in some areas of the state.  Requiring a LMHP to be available in real time with a QMHP to complete a prescreening is a waste of resources.  Prescreeners were grandfathered or have been conducting pre-admission screenings for many years.  To say that they are no longer able to bill for a service that has been performed for years by a particular staff solely based on their credentials effective December 1 does not make sense and will be detrimental to the community due to reduced workforce staffing.  A staff person certified by DBHDS should have the ability to bill for the service.  The CSB is the backbone of crisis services in the community and employs good clinicians to provide the services. There is no reason why a DBHDS prescreener could not provide preadmission screening or mobile crisis services.  In fact, a prescreener would have more clinical training than a CSAC or QMHP would have to respond to crisis situations.  The prescreening service should be pulled out from mobile crisis and billed as a separate service item to reduce confusion.

 

Community Crisis Stabilization

Requirement of crisis hotline referral as a condition of billing does not allow for consumers to transition between levels of crisis care smoothly based on need – for example it is not reasonable for a consumer served in 23 hour crisis observation to require a separate crisis hotline call to be referred for community crisis stabilization

The assessment for Crisis Stabilization is not defined as to what would be acceptable as the third option to enter the service.

If it is expected that a CEPP be used for the crisis services, what does this look like?  REACH has a CEPP and it is lengthy.  This is a concern as to time spent documenting when essential services can be provided to the individual who is in crisis.

 

23- Hour Crisis Stabilization

                Psychiatric evaluation requirement: 

Regulations states psychiatric evaluation must be available at the time of admission which is inappropriate clinically and should only be required when assessed by the LMHP type to be necessary.  Not all consumers will require psychiatric evaluation and prescribing of medication during this service.

Unable to occur due to workforce shortages there are simply not funds to pay for nor psychiatrist/ psychiatric nurse practitioners available to provide this service 24 hours per day

 

24/7 Registered Nurse Requirement:

The U.S. is in the midst of a pandemic and well documented nursing crisis.  The requirement for 24 Registered Nurse (RN) coverage is unnecessary and staffing to support this is unavailable in the current workforce.

The allowance for use of a Licensed Practical Nurse is unhelpful because it requires an RN to be at the facility. 

If nursing is a required component it should be on an as needed basis- available to respond to the location OR allow for LPN level nursing with access to an RN by phone for oversight/ supervision.

This requirement is cost prohibitive and cannot be accomplished by providers with a December 1, 2021 implementation date.

Earlier draft of regulations did not require 24/7 RN staffing, including those draft regulations circulated by DMAS in August 2021.

There is contradictory language about who can provide assessment: In some sections it indicates Physician Assistants can provide care and then later allows only psychiatrist or psychiatric Nurse Practitioner to provide care.

 

Other concerns

                Assessment- 23 hour & CSU level

References to multiple assessments that may be used/ required.  Assessment should be consistent with other services and utilize the Comprehensive Needs Assessment for this purpose without creating additional assessments that will require consumers to repeat their stories and are redundant.

Assessment should align with the CNA requirements for ARTS so that two separate assessments are not required.

 

Crisis Education and Prevention Plan

Required for multiple services.  This is unnecessary, particularly in more acute, shorter term services such as stabilization and 23 hour observation- Current CEPP used by REACH is excessively cumbersome.

CommentID: 116619
 

11/4/21  1:20 pm
Commenter: Rebekah Brubaker, HRCSB

RCSUs
 

Residential Crisis Stabilization Units

My primary concerns are related to the requirements of 24/7 RN coverage and having a psychiatric evaluation done at the time of admissions.  It seems that it would be appropriate to allow RCSUs to be staffed by LPNs without RNs on-site if the LPNs have access to RN, NP, MD etc. for guidance/work direction etc. If this adjustment is not approved and updated in the manual, I believe that several RCSUs will not be able to operate and thus compounding the issue bed shortages and alternative placements to inpatient hospitalizations. I am also advocating for the psychiatric evaluation to be done within 24-48 hrs of admission and not "at the time" of the admission, as clients are already undergoing several assessments/screenings at the time of entry into the program.  I have also included several specific areas that it would be helpful for language/expectations to be updated or clarified.

  • Pg. 32 (First bullet): “A psychiatric evaluation by a psychiatrist, nurse practitioner or physician assistant must be available at the time of admission into the service.”
    • Consider revising the statement "at the time of admission" to allow for a 24-hour period or longer depending on if they are stepping down from a higher level of care. It does not seem client-centered or trauma informed to have clients sit through multiple assessments at the time of admissions if there is recent information that can be reutilized.
  • Pg. 32 (Third bullet): “The Crisis Education and Prevention Plan (CEPP) meeting DBHDS requirements is required for this service and must be current. The CEPP process should be collaborative but must be directed and authorized by a LMHP, LMHP-R, LMHP-RP or LMHP-S.”
    • What are DBHDS required components for the CEPP? It is essential for us to have that information prior to 12/1/2021 so that we can create the necessary forms/documentation/processes to incorporate this new requirement.
  • Pg. 35 (Staff Requirements, fifth paragraph): “Nursing services shall be provided by a RN or a LPN working directly under an RN who is present on the unit.”
    • This is a change from previous, as on-site nursing was not required for Crisis Stabilization, only Withdrawal Management. Now, not only will nursing coverage be required 24/7, but a RN must be present at all times. This will present significant challenges for recruitment and staffing. Recommend Staff Requirements to say “Nursing services shall be provided by a RN or a LPN working directly under an RN who is either present on the unit or available by telephone.”
  • Pg. 33 (First bullet): “On the day of admission, at a minimum, RCSU providers must provide assessment, psychiatric evaluation and a nursing assessment.”
    • Currently, psychiatric evaluation is required to be completed within 24 hours, so may not be done on the day of admission. Evening admissions will often not be able to complete these three assessments before midnight. Recommend changing the time frame from “On the day of admission…” to “Within 24 hours of admission…” or even longer if the individual is setting down from a higher level of care.
  • Pg. 32 (3rd bullet)

“The Crisis Education and Prevention Plan (CEPP) meeting DBHDS requirements is required for this service and must be current. The CEPP process should be collaborative but must be directed and authorized by a LMHP, LMHP-R, LMHP-RP or LMHP-S.” and

Pg. 36 (first paragraph)

“Treatment Planning must be provided by an LMHP, LMHP-R, LMHP-RP, LMHP-S; QMHP-A, QMHP-C, QMHP-E, CSAC* or CSAC Supervisee*.”

  • Does the CEPP replace the Treatment Plan or is it in addition to it? Both are mentioned in these sections, and the staff who are qualified to complete them require different credentials. Recommend to clarify if the CEPP replaces the Treatment Plan or is in addition to it, and confirm the credentials of the staff who completes it.

 

CommentID: 116620
 

11/4/21  1:24 pm
Commenter: Rebekah Brubaker, HRCSB

Crisis Hotline
 

Several times in the manual it notes that referral must come from Crisis Hotline, I believe this language does not allow for services to be initiated locally by individuals who are familiar with providers in their community.  This seems like it could be an additional barrier to helping individuals access care if they are told that they need to contact the Crisis Hotline to receive the referral. 

In addition, due to the fact that many regions do not have the call centers operating and most likely will not have them operationalize by the time this manual goes into effect, additional consideration should be given for providers to begin providing services without engagement or referrals from the Crisis Hotline. 

 

CommentID: 116621
 

11/5/21  1:57 am
Commenter: Walter Simms, Jr. Danville-Pittsylvania CSB

Mobile Crisis Response
 

Mobile Crisis Response Crisis Hotline Requirement: The requirement to receive the referral from the Crisis Hotline to obtain payment for work performed is a concern. Referrals for crisis services come from various avenues (law enforcement/emergency room/private providers/self-referrals, 24 hour emergency services line, etc.). Self-referrals are received from individuals showing up at the door indicating a crisis. It seems that the requirement for a referral to come from the crisis hotline is an added step that hinders positive customer service and hinders the staff by taking away from the customer who needs the service immediately. There are organically occurring referrals in crisis. Questions: The crisis services and the crisis transformation relies heavily on the positive interaction among community partners. When law enforcement or other community partners must go through a regional crisis hotline in order to access a service, it is concerning that these relationships will be burdened with a third party contact. Who is responsible for making these calls to the crisis hotline? What is the purpose of calling the hotline to utilize a service that the CSB has always performed/provided? In addition, the Code of Virginia states that law enforcement agencies are to notify the CSB of an executed Emergency Custody Order. It is concerning that the requirement to receive a referral from the crisis hotline would create room for error and delayed time. These calls should come directly to the CSB. If the purpose of the requirement is to collect data, the regulations should spell out the expectation is to contact the crisis hotline to log a contact, not receive a referral and payment for a service. Mobile Crisis Response Assessment: The draft of the Medicaid manual does not clarify what kind of assessment is acceptable. Since a preadmission screening is a service that can be provided under the mobile crisis service, it would be suggested that the prescreen be a tool to use for the mobile crisis assessment. A determination would need to be made as to whether or not an individual needed involuntary psychiatric hospitalization or not in the midst of the crisis. When the individual does not meet involuntary hospitalization criteria, then the prescreen could be used as a mechanism to begin for mobile crisis response/services. Staff requirements to complete a pre-admission screening: The requirement of an LMHP or LMHP eligible staff person to complete the pre-screening will have a negative impact on the workforce in some areas of the state. Requiring a LMHP to be available in real time with a QMHP to complete a prescreening is a waste of resources. Prescreeners were grandfathered or have been conducting pre-admission screenings for many years. To say that they are no longer able to bill for a service that has been performed for years by a particular staff solely based on their credentials effective December 1 does not make sense and will be detrimental to the community due to reduced workforce staffing. A staff person certified by DBHDS should have the ability to bill for the service. The CSB is the backbone of crisis services in the community and employs good clinicians to provide the services. There is no reason why a DBHDS prescreener could not provide preadmission screening or mobile crisis services. In fact, a prescreener would have more clinical training than a CSAC or QMHP would have to respond to crisis situations. The prescreening service should be pulled out from mobile crisis and billed as a separate service item to reduce confusion. Community Crisis Stabilization Requirement of crisis hotline referral as a condition of billing does not allow for consumers to transition between levels of crisis care smoothly based on need – for example it is not reasonable for a consumer served in 23 hour crisis observation to require a separate crisis hotline call to be referred for community crisis stabilization The assessment for Crisis Stabilization is not defined as to what would be acceptable as the third option to enter the service. If it is expected that a CEPP be used for the crisis services, what does this look like? REACH has a CEPP and it is lengthy. This is a concern as to time spent documenting when essential services can be provided to the individual who is in crisis. 23- Hour Crisis Stabilization Psychiatric evaluation requirement: Regulations states psychiatric evaluation must be available at the time of admission which is inappropriate clinically and should only be required when assessed by the LMHP type to be necessary. Not all consumers will require psychiatric evaluation and prescribing of medication during this service. Unable to occur due to workforce shortages there are simply not funds to pay for nor psychiatrist/ psychiatric nurse practitioners available to provide this service 24 hours per day 24/7 Registered Nurse Requirement: The U.S. is in the midst of a pandemic and well documented nursing crisis. The requirement for 24 Registered Nurse (RN) coverage is unnecessary and staffing to support this is unavailable in the current workforce. The allowance for use of a Licensed Practical Nurse is unhelpful because it requires an RN to be at the facility. If nursing is a required component it should be on an as needed basis- available to respond to the location OR allow for LPN level nursing with access to an RN by phone for oversight/ supervision. This requirement is cost prohibitive and cannot be accomplished by providers with a December 1, 2021 implementation date. Earlier draft of regulations did not require 24/7 RN staffing, including those draft regulations circulated by DMAS in August 2021. There is contradictory language about who can provide assessment: In some sections it indicates Physician Assistants can provide care and then later allows only psychiatrist or psychiatric Nurse Practitioner to provide care. Other concerns Assessment- 23 hour & CSU level References to multiple assessments that may be used/ required. Assessment should be consistent with other services and utilize the Comprehensive Needs Assessment for this purpose without creating additional assessments that will require consumers to repeat their stories and are redundant. Assessment should align with the CNA requirements for ARTS so that two separate assessments are not required. Crisis Education and Prevention Plan Required for multiple services. This is unnecessary, particularly in more acute, shorter term services such as stabilization and 23 hour observation- Current CEPP used by REACH is excessively cumbersome.

CommentID: 116681
 

11/5/21  9:11 am
Commenter: Robert Ritchey

Resource Needs
 

In my position, I assist college students with accessing mental health intensive treatment options when warranted and then meet with them following discharge from various facilities across the state.  I feel others have addressed many of the specific issues/aspects concerning the proposed changes in the other comments, so I will speak on potential impacts of limiting resources at a time when they are critically needed.  Our most utilized resource is our local crisis stabilization unit through New River Valley Community Services.  The feedback from students regarding the interventions and benefits they receive from the crisis stabilization unit far outpace any other intensive treatment options available. It would be extremely detrimental for us to lose this as resource.  We are in a fairly rural area and when local beds are unavailable we have students sent all across Virginia (often transported cuffed in the back seat of police vehicles when under a Temporary Detention Order).  Many of these students are international students and once they are discharged, we end up trying to assist them with bus options, taxi services, etc. to try to help them return to the Blacksburg area. Having excellent care right nearby through our crisis stabilization unit benefits not only our students but the community at large.  There needs to be some careful foresight and flexibility to ensure the state is not limiting available options through possibly well-meaning regulations which further imperils an already inadequate mental health safety net.

CommentID: 116682
 

11/5/21  9:26 am
Commenter: Jenny Dye

DMAS Changes will impact services available
 

Although I appreciate the effort to strengthen staffing, the proposed DMAS changes during a labor shortage for mental health providers, nursing staff, and psychiatrist may to led to closure of valuable crisis stabilization units, crisis centers, and therefore reduce options for individuals in need of support.  Inpatient mental health facilities are already struggling to manage the demand for emergency mental health care. 

Please delay implementation of the regulations requiring LPN on site as well as the requirement of psychiatry evaluation at the time of admission.  Please clarify how a regional crisis hotline will function for individuals on site with a client in need and not able to directly connect to their local emergency provider. 

CommentID: 116683
 

11/5/21  9:32 am
Commenter: Cristi Aaron; DPCS

Crisis Services Concerns
 

Crisis Hotline Requirement:

The requirement to receive the referral from the Crisis Hotline to obtain payment for work performed is a concern.  Referrals for crisis services come from various avenues (law enforcement/emergency room/private providers/self-referrals, 24 hour emergency services line, etc.).  Self-referrals are received from individuals showing up at the door indicating a crisis.  It seems that the requirement for a referral to come from the crisis hotline is an added step that hinders positive customer service and hinders the staff by taking away from the customer who needs the service immediately.  There are organically occurring referrals in crisis. 

Questions:  The crisis services and the crisis transformation relies heavily on the positive interaction among community partners.  When law enforcement or other community partners must go through a regional crisis hotline in order to access a service, it is concerning that these relationships will be burdened with a third party contact.  Who is responsible for making these calls to the crisis hotline?  What is the purpose of calling the hotline to utilize a service that the CSB has always performed/provided?  In addition, the Code of Virginia states that law enforcement agencies are to notify the CSB of an executed Emergency Custody Order.  It is concerning that the requirement to receive a referral from the crisis hotline would create room for error and delayed time.  These calls should come directly to the CSB.  If the purpose of the requirement is to collect data, the regulations should spell out the expectation is to contact the crisis hotline to log a contact, not receive a referral and payment for a service.

 

Mobile Crisis Response Assessment:

The draft of the Medicaid manual does not clarify what kind of assessment is acceptable.  Since a preadmission screening is a service that can be provided under the mobile crisis service, it would be suggested that the prescreen be a tool to use for the mobile crisis assessment.  A determination would need to be made as to whether or not an individual needed involuntary psychiatric hospitalization or not in the midst of the crisis. When the individual does not meet involuntary hospitalization criteria, then the prescreen could be used as a mechanism to begin for mobile crisis response/services.

 

Staff requirements to complete a pre-admission screening:

The requirement of an LMHP or LMHP eligible staff person to complete the pre-screening will have a negative impact on the workforce in some areas of the state.  Requiring a LMHP to be available in real time with a QMHP to complete a prescreening is a waste of resources.  Prescreeners were grandfathered or have been conducting pre-admission screenings for many years.  To say that they are no longer able to bill for a service that has been performed for years by a particular staff solely based on their credentials effective December 1 does not make sense and will be detrimental to the community due to reduced workforce staffing.  A staff person certified by DBHDS should have the ability to bill for the service.  The CSB is the backbone of crisis services in the community and employs good clinicians to provide the services. There is no reason why a DBHDS prescreener could not provide preadmission screening or mobile crisis services.  In fact, a prescreener would have more clinical training than a CSAC or QMHP would have to respond to crisis situations.  The prescreening service should be pulled out from mobile crisis and billed as a separate service item to reduce confusion.

 

Community Crisis Stabilization

Requirement of crisis hotline referral as a condition of billing does not allow for consumers to transition between levels of crisis care smoothly based on need – for example it is not reasonable for a consumer served in 23 hour crisis observation to require a separate crisis hotline call to be referred for community crisis stabilization

The assessment for Crisis Stabilization is not defined as to what would be acceptable as the third option to enter the service.

If it is expected that a CEPP be used for the crisis services, what does this look like?  REACH has a CEPP and it is lengthy.  This is a concern as to time spent documenting when essential services can be provided to the individual who is in crisis.

 

23- Hour Crisis Stabilization

                Psychiatric evaluation requirement: 

Regulations states psychiatric evaluation must be available at the time of admission which is inappropriate clinically and should only be required when assessed by the LMHP type to be necessary.  Not all consumers will require psychiatric evaluation and prescribing of medication during this service.

Unable to occur due to workforce shortages there are simply not funds to pay for nor psychiatrist/ psychiatric nurse practitioners available to provide this service 24 hours per day

 

24/7 Registered Nurse Requirement:

The U.S. is in the midst of a pandemic and well documented nursing crisis.  The requirement for 24 Registered Nurse (RN) coverage is unnecessary and staffing to support this is unavailable in the current workforce.

The allowance for use of a Licensed Practical Nurse is unhelpful because it requires an RN to be at the facility. 

If nursing is a required component it should be on an as needed basis- available to respond to the location OR allow for LPN level nursing with access to an RN by phone for oversight/ supervision.

This requirement is cost prohibitive and cannot be accomplished by providers with a December 1, 2021 implementation date.

Earlier draft of regulations did not require 24/7 RN staffing, including those draft regulations circulated by DMAS in August 2021.

There is contradictory language about who can provide assessment: In some sections it indicates Physician Assistants can provide care and then later allows only psychiatrist or psychiatric Nurse Practitioner to provide care.

 

Other concerns

                Assessment- 23 hour & CSU level

References to multiple assessments that may be used/ required.  Assessment should be consistent with other services and utilize the Comprehensive Needs Assessment for this purpose without creating additional assessments that will require consumers to repeat their stories and are redundant.

Assessment should align with the CNA requirements for ARTS so that two separate assessments are not required.

 

Crisis Education and Prevention Plan

Required for multiple services.  This is unnecessary, particularly in more acute, shorter term services such as stabilization and 23 hour observation- Current CEPP used by REACH is excessively cumbersome.

CommentID: 116684
 

11/5/21  10:02 am
Commenter: Erica Coates, Cook Counseling Center, Virginia Tech

Too much, too soon
 

My understanding of the 12/1/21 updates will have deleterious impact on local resources that are critically important for responding to mental health emergencies in the New River Valley.  In a period where all sectors are facing understaffing, it is not the time to elevate staffing regulations, particularly for nurses.  The impact of well-meaning regulations would be that some of our most used and needed resources in rural SWV would have to close, thus increasing demand at other resources far from our locality.  Students of Virginia Tech are my clients, and those without health insurance or transportation or family support will be at severe disadvantage when their mental health becomes an emergency.  We cannot reduce the number of crisis beds in this area, and we cannot reduce the ability of non-profits such as NRVCS to serve impoverished and undersupported individuals.  Please remove updates on staffing requirements at this time, and if they must be added, please do so in a more gradual time frame when every sector across the economy is not already understaffed.  This is not the time for these changes.  Thank you for your consideration.

CommentID: 116685
 

11/5/21  10:21 am
Commenter: Brooke Mitchell, Loudoun County MHSADS

Appendix G Comments
 

Appendix G requires that the hotline is called PRIOR to the initiation of crisis services.  This requirement is not feasible and has the potential to negatively impact the individual.  It is recommended that the agency consider a modification to “within one business day” rather than prior to initiation of crisis intervention.

 

Appendix G requires the providers “deploy in real-time to the location of the identified crisis.”  The Appendix is not clear as to reimbursements pertaining to transportation time.  We seek clarification regarding whether transportation time will be reimbursable.

 

Appendix G also requires a “referral from the Crisis Hotline” to bill for mobile crisis.  This requirement could potentially harm the individual by causing a delay in care when referrals are made directly by CSB staff or through law enforcement.  We ask that the agency consider modification of this requirement. 

 

According to Appendix G, “Submission of registrations [for Mobile Crisis Response reimbursement] must be within 1 business day of admission.”  The 1 business day requirement is shorter than the current time allowed to submit registration and creates an additional administrative burden for providers.  We ask that the agency consider maintaining current time frame.

CommentID: 116686
 

11/5/21  10:24 am
Commenter: Lydia Qualls, Virginia Tech Cook Counseling Center

Changes too soon will negatively impact services available
 

Although it is important to provide clients with the best care possible, the proposed changes are coming during a labor shortage of all mental health providers, nurses, and psychiatrists. Implementing these proposed changes now may lead to the closure of resources we use with our most vulnerable students, such as crisis stabilization units, crisis centers. Inpatient mental health facilities are already struggling to manage the demand for emergency mental health care. 

Please delay implementation of the regulations requiring LPN on-site as well as the requirement of psychiatry evaluation at the time of admission.  Please clarify how a regional crisis hotline will function for individuals on-site with a client in need and not able to directly connect to their local emergency provider. 

CommentID: 116687