37 comments
This requirement for PE and labwork prior to admission to MAT could delay starting clients on MAT when clients are not compliant with obtaining physical exams or labwork. This could result in client death due to untreated opioid use disorder.
It is often difficult to reach private providers of MAT, and too often efforts to obtain records are futile or take a long time. Attempts to contact these providers seem reasonable once the client has been admitted into MAT program, but to delay services based on this requirement could result in increase numbers of overdoses of individuals with opioid use disorder
Current ARTS guidelines for OBATS state specifically that MAT should not be withheld based on an individual's failure to attend counseling sessions, because individuals with opioid use disorder are at different stages in their willingness to engage in counseling.
Virginia Association of Medication Assisted Recovery Programs
A Member of 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" />
Department for Behavioral Health and Developmental Services
1220 Bank Street
Richmond, VA 23219
Re: Amendments to draft regulations
Dear DBHDS Colleagues:
We would first like to express our appreciation for considering feedback from providers and making amendments that will allow us to better provide appropriate substance use disorder treatment services. Please find below the recommended amendments and rationales we are requesting be considered.
Section A.2.g States: Providers shall implement screening policies and procedures that include: Medications currently being used including recent increases, decreases, or discontinuation, misuse, or overdose of prescription medication.
Recommend just saying, “Medications currently being used.”
12VAC35-109-50. Secondary Screening
Section A States: In the event that an individual was placed on a waitlist prior to receiving services, a secondary screening shall be performed prior to admission to the service.
Recommend adding “for 90 days or more” after the word “waitlist”
12VAC35-109-180. Lighting
Section A Requires artificial lighting to be “by electricity”
Recommend removing this section
12VAC35-109-200. Standards for the evaluation of new licenses for providers of services to individuals with opioid addiction.
Section E.3. States: The medical director shall be a physician. The medical director shall be a board-certified
addictionologist or have successfully completed or will complete within one year a course of
study in opiate addiction that is approved by the department, shall have completed an accredited
residency training program, and shall have at least one year of experience in addiction medicine
or addiction psychiatry.
Recommend removing the stipulation of having one year in addiction medicine or psychiatry
Section E.5. States: A minimum of one registered nurse (RN) staffed with licensed practical nurses (LPNs), if
warranted to meet the needs and number of patients served. All LPNs hired shall be supervised by
a RN.
Recommend removing the criteria of having an RN
Section E.6. States: Counselors shall be licensed or certified by the applicable Virginia health regulatory board eligible for this license or certification, and a minimum of two thirds (63%) of counselors working with individuals in an outpatient treatment program (OTP) program must be licensed or certified. No more than one third (33%) of counselors in a program can be eligible for license or certification.
Recommend removing “minimum of two thirds (63%) of counselors working with individuals in an outpatient treatment program (OTP) program must be licensed or certified. No more than one third (33%) of counselors in a program can be eligible for license or certification.”
Section E.7. States: Personnel to provide support services which shall include at least one security guard trained in accordance with 12VAC35-105-440, 12VAC35-105-450, and 12VAC35-105-460
Recommend removing this section entirely as a requirement
Section G States: If there is a change in or loss of any staff in the positions listed in subsection E, the department
requires written notification and a plan for immediate coverage within one week
We agree with these criteria as it pertains to section E. 1-4.
Recommend removing this requirement for all other subsections under E
Section H.3. States: The medical director shall be responsible for ensuring all medical, psychiatric, nursing, pharmacy, toxicology, and other services offered by the OTP are conducted in compliance with federal regulations at all times; and, shall be present at the program for a sufficient number of hours to ensure regulatory compliance and carry out those duties specifically assigned to the medical director by regulation. The medical director shall be present at a minimum one hour per every 50 patients
Recommend removing the last line stating the medical director shall be present at a minimum of one hour per every 50 patients
Section H.4. States: Counselors shall meet the following caseload requirements: The caseload size for a licensed or certified counselor shall not exceed 45 patients. The caseload size for a nonlicensed or noncertified counselor shall be assigned from the licensed counselor's caseload and caseload size shall not exceed 30 patients.
Recommend removing caseload limit
Section I.4. States: Plans for on-site onsite security and services adequate to ensure the safety of patients, staff, and property
Recommend removing “on-site security”
Section J.7. States: All staff shall be certified in First Aid, CPR, and Naloxone administration
Recommend changing the word “certified” to “trained”
12VAC35-109-250. Service operation schedule
Section B.2. States: The provider receives prior approval from the state opioid treatment authority (SOTA) for Sunday closings. Each program must have a policy that addresses medication for the newly inducted patients and those who are deemed at risk, i.e., still actively using illicit substances or medical issues that may warrant closer monitoring of medication. This policy must include openings on Sundays for the population described above
Recommend keeping the first sentence and eliminating the rest; or change the wording to state that programs will follow federal guidelines regarding Sunday closings.
12VAC35-109-260. Initial and periodic assessment services
Section C States: Upon admission and annually, all individuals shall sign an authorization for disclosure of information to allow programs access to the Virginia Prescription Monitoring System (PMP). Failure to comply with this requirement shall be grounds for denial of admission to the program. Programs shall run a PMP report each month on every individual served. The program physician shall provide this report. The report shall be stored in the individual's file and must be marked "DO NOT DUPLICATE."
Recommend removing the sentence, “Programs shall run a PMP report each month on every individual served.”
Section E States: Initial tests conducted by the provider shall include viral hepatitis, HIV and other sexually transmitted infections. On admission, all individuals shall be offered testing for AIDS/HIV. The individual may sign a notice of refusal without prejudice. The individual shall be certified as tuberculosis (TB) free upon admission and annually by a qualified licensed professional
Recommend remove the requirement of the test being conducted at the facility.
Recommend programs provide patients with education about infectious diseases and offer referrals to places that can perform the testing
12VAC35-109-280. Counseling sessions
Section A.1. States: The provider shall conduct face-to-face counseling sessions (either individual, group, or family) of one hour minimum. The provider shall document details of each session including the length within the individual's service record. The counseling sessions shall occur:
1. Every week for the first six months of the first year of the individual's treatment.
Recommend keeping this regulation as it currently is stating counselors shall meet with individual 2x per month for the first year
12VAC35-109-290. Drug screens
Section 2 States: Perform a random weekly drug screen whenever an individual's drug screen indicates
continued illicit drug use or when clinically and environmentally indicated
Recommend removing this subsection
12VAC35-109-300. Take home medications
Section A-C Regarding criteria for and schedule of take home medications
Recommend removing these sections
Recommend using the wording, “Medications used for the treatment of opioid use disorder to be dispensed to patients for unsupervised or “take home” use shall comply with the scheduling requirements set forth in 42 CFR Part 8 MEDICATION ASSISTED TREATMENT FOR OPIOID USE DISORDERS
Thank you for your support and willingness to work with providers as these regulations are amended. Please feel free to contact us with any questions or if we can be of assistance in any other way.
Respectfully,
David Cassise
David Cassise
VAMARP President
Regional Director
Pinnacle Treatment Centers
Cc: Jodi Herndon, VAMARP Vice President
Melissa Brown, VAMARP Treasurer
Stacie Shifflett, VAMARP Secretary
VAMARP Member Programs
12VAC35-109-280. Counseling sessions
The initial requirements for weekly for 6 months ... this is unrealistic in our current environment. Transportation is extremely problematic, child care becomes problematic and safety concerns increase. Patients new to recovery need to be met where they are in the treatment spectrum.
Many of the specific regulations in this proposal seem specifically designed to force existing opioid maintenance treatment programs out of business and to inhibit the ability of new programs offering new services to open. This is occurring in light of an ever increasing overdose epidemic, in which Virginia is seeing overdose rates above the national average. As most other regulatory authorities are begging treatment providers to find ways to reduce barriers to care, get more patients into treatment, and retain them, these regulations seem particular restrictive in preventing allowing programs to do just that. Specifically:
12VAC35-109-40; 12VAC35-109-50: Regarding increased screening questions for patients. Anytime that a patient calls interested in obtaining treatment a treatment program should be open to seeing that patient and evaluating them for possible admission. Additional screening questions before a patient can even be considered for admission serve no purpose other than to set up an additional barrier to treatment. A full evaluation of the patient will always be done before it is decided if the patient is appropriate for admission and treatment. There seems to be no purpose to mandate additional screening of patients, beyond questions such as “Are you using opiates and are you looking for help?” before providing them an opportunity for a full and comprehensive evaluation.
12VAC35-109-200: Staffing qualification requirements. While enhanced staffing training and certifications would always be desirable it is just not reasonable to require additional staffing restrictions during a time when there are marked staffing shortages everywhere. These regulations will have a significant effect on the ability of many treatment programs to operate. There are simply not enough board certified addition physicians, or even physicians well trained in addiction medicine to fill the required positions. As the nation faces a national physician shortage there are virtually no places where a physician can learn about addiction treatment, particularly about addiction treatment with methadone, outside of the OMT environment. Training on the job is the rule. Furthermore, to allow this necessary training on the job there must be the ability to allow other more appropriately trained and certified physicians to leverage their skills to multiple locations that require them. This will entail the ability to supervise multiple mid-level providers as well as other physicians that may not be well trained in addiction medicine. All of this supervision can be done remotely with currently available technology and EMR systems. An arbitrary requirement of onsite time per patient enrolled in the program makes no sense. Well trained physician time must be maximized and efficiently utilized. Travelling to multiple locations to meet an onsite time requirement is not an efficient use of this scarce resource.
The same work force situation exists with the proposed requirements for RNs as opposed to LPNs and the minimum counselor certifications and maximum counselor to patient restrictions. Many OTPs will simply not be able to find an adequate number of personnel to fill the needed positions.
There are multiple other proposed requirements in this draft document that are just not able to be done, or are extremely impractical to implement, due to staffing, facility, funding, time, and other limitations. Implementation of these regulations as proposed will result in a marked decrease in the amount of opioid maintenance treatment available to the citizens of Virginia and a subsequent increase in the number of opioid overdoses in addition to increases in other morbidity and mortality secondary to inadequately treated opiate use disorders. I would urge significant reconsideration of many of these proposals with more input from those on the ground who are diligently working to provide care to the most number of patients in the most efficient way possible.
Please also consider the very detailed comments previously posted by David Cassise, the President of VAMARP.
The implementation of these proposals, unchanged, will significantly impair the ability to provide opioid maintenance treatment in the state of Virginia. These proposals set up multiple significant barriers to treatment that are directly contrary to the national movement being lead by SAMHSA and ASAM trying to make addiction treatment more focused on harm reduction and available to the most number of people possible.
Thank you for your attention to these serious matters. Please let me know if I can provide you with any additional information.
In response to the proposed changes, I am in agreement with the responses made by Dr. Tannenbaum and David Cassise. I would like to elaborate specifically regarding to the counseling ratio proposals. As a licensed clinical social worker who practices privately in addition to serving as the Director of Clinical Services for ARS for many years, I have seen many barriers implemented through regulations across states that hinder OTP's ability to provide quality care and/or serve as a reason for citations. As others have stated, it is without a doubt desirable to have counselors who are certified and/or licensed. With a requirement of 63% certified counselors with a maximum caseload of 45 and the remainder of uncertified counselors with a maximum caseload of 30, this will only further provide barriers to care. An important aspect of this is having regular supervision where as a licensed supervisor works closely with the counseling staff. Whether someone is certified or not, will not necessarily dictate their ability to provide quality care to those we serve.
In addition to the ratio's and credentials mentioned above, requiring a minimum of one hour counseling per week for the first 6 months, is unrealistic. In order to provide patient centered care, the counselors are trained to meet clients where they are. For some, this is an unrealistic expectation and does not equate success and may further push our pre-contemplative clients; clients suffering with mental illness; and clients with unresolved trauma from attending treatment altogether. Best practices will dictate if clinically indicated a patient will have additional counseling which may equate to weekly or more. For some, weekly counseling may not be clinically indicated.
I am in agreement if a ratio is needed, a 60:1 ratio is realistic and provides counselors with plenty of time throughout the month to meet the needs of the individuals served. I would be more than happy to provide additional information for this if requested.
Thank you for giving me the opportunity to make comments on the draft Center-Based Chapter. You will find my comments and recommendations below.
Throughout the entire document, I would like to recommend removing Substance Abuse and replacing it with Substance Use Disorder. I also recommend removing Mental Retardation with Developmental Disability/Intellectual Disability.
12VAC35-109-10
I would like to recommend adding a definition for Supported Decision Making to this section
12VAC35-109-40
Recommend changing Medical Symptoms to Medical Conditions.
12VAC35-109-40
Recommend changing Medical Symptoms to Medical Conditions.
12VAC35-109-60
D. Add “and available” after if applicable.
12VAC35-109-70
A.1 & 2 Recommend changing 24 hours after admission to 1 business day.
12VAC35-109-80
E. While I agree that employees should be knowledgeable about the contents of ISPs for individuals served, establishing expectations to train and test all employees involved with service delivery is an unrealistic expectation that will significantly detract from service delivery. Observations of competency and knowledge about providing services is part of the supervisory and evaluation process. Moving forward with this is likely to result in providers making fewer updates to ISPs, to avoid retraining and testing employees. There is no practical way to document this knowledge and competency without documentation of confidential information about individuals served, which should not be part of a Personnel File. This expectation places an undue burden on Human Resources who would have to maintain the documentation, as well as supervisors who would have to develop ways to test and train employees while maintaining their other responsibilities.
12VAC-109-90
C. Asking for clarification if quarterlies are required for this service.
12VAC35-109-100
B.5 This would be easier to identify for some services, such as outpatient, but not for a day program. This is an impractical expectation for daily service documentation..
B.6 Replace clinal staff with qualified staff.
C Add informational notes along with communication logs and supervision notes.
12VAC35-109-120
A.3 & 4 Recommend to remove will provide as we cannot provide medical or dental services as we are not medical professionals.
12VAC35-109-130
B.2.b Remove as this pertains to residential services, not center-based services.
12VAC35-109-150
E Please make consistent throughout DBHDS regulations. The temperature range for center-based services is different than the temperature range for residential.
12VAC35-109-200
G This is an impractical expectation for programs due to the administrative burden. This is not required for any other DBHDS licensed service, request this requirement to be removed.
INITIAL DRAFT: NEW Center-Based Service Specific Chapter (109) for 12VAC35-105, Rules and Regulations for Licensing Providers by the Department of Behavioral Health and Developmental Services
12VAC35-109-80 ISP Requirements
E.2 Provider shall test the employee or contractor's knowledge, competency, or both and retain documentation of test with in the employees file.
We appreciate the opportunity to review this section. In order to fully comment and understand the regulatory language, and the full context provided, it is helpful to have all the chapters to comment on at once.
12VAC35-109-10. Definitions |
Wondering why “Center Based Respite Care services” is included here rather than in chapter regarding residential services?
Developmental Disability Professional “Interesting aspect to add this information- Does this line up with DMAS definition?”
Qualified Mental Health Professional Eligible “Board of Counseling utilizes language of Qualified Mental Health Progression Trainee or QMHP-T. Please change to match Board of Counseling in definitions and throughout regulations.”
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12VAC35-109-20. Services
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12VAC35-109-30. Service descriptions
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“Having definitions here could be problematic as will they align with DMAS regulations? If one changes the other might not; there needs to be a way for them to reference to the same place---otherwise we are going to be in an ongoing struggle to figure out what to do when one or the other changes. This adds administrative burden to providers.”
Section A
“Appreciate this language as often services are talked about to "cure"
Section K
“Continue to find it interesting this is included here rather than in a residential section
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12VAC35-109-40. Screening.
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“Is this new? I cannot find 109-40. This seems to be more requirements than current practice for screening” A.2.e. Current Diagnoses: Diagnostic is part of the intake process and not screening. Request to amend this to state current diagnoses from medical providers as appropriate. |
12VAC35-109-50. Secondary Screening
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- “This section should indicate a time frame for when this is needed----and can this be part of the assessment rather than a separate screening?
Additionally, admission is defined in the definition section as ""Admission" means the process of acceptance into a service as defined by the provider's policies.
Thus, admission is a process so figuring out when a secondary screening is required could prove challenging.”
“Can this also be at the time of admission? Someone's placement on a waitlist might be a very short period of time (ie 48 hours).”
Waitlist needs to be defined.
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12VAC35-109-60. Assessment.
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Section C: Please define “medical screenings.”
Section F.1.g “This seems a bit like a catch all that might be overused. I would like something more specific that indicates what should be addressed otherwise, we are on a slippery slope of not being able to meet this expectation”
Section F.2 “Concern about what is meant for high risk for medical complications---If we mean concerns of complications because of detox, that is one thing and can see this as appropriate; however, if this is general medical complications what is expected, we are not physical doctors. I think this statement about pose a danger to self or others for substance abuse places into stereotypes”
“What is the definition of high-risk here?”
Please specify medical complications due to substance use.
Section G.6 “Understand this is an important aspect around case management; What is the expectation of other center-based services to address? If it is in the assessment, it means it has to be in the provider's ISP. So, what is this expectation.”
Section G.10 I think using “competency,” which is a legal term, in a sentence about AR and rep payee is conflating the use of “competency” and “compacity.”
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12VAC35-109-70. Individualized services plan (ISP); Individualized supports plan; Service planning
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Section A.1 “This is problematic. For most DD services, authorization is required prior to beginning services. To get the authorization, plans must be updated. Thus, this may be done before admission.”
“Completed within 60 days of what? See previous comments about concern of using "admission".”
Section B “Is A 1 and A 2 supposed to take the place of this information? Otherwise, this seems repetitive.”
Section C This section seems to repeat what is in A.2”
Section D “Why is this statement put here and not in the case management section? Not sure why this needs to be state here--- Also, even if the person has a case manager, the ISP needs to be developed including the information below. I'm confused on what is being state here.”
Section D.1.C “This one has always been a concern as it is not well defined. What is there are alternatives to the service or alternatives to the service provider? Is this the benefits of receiving the service with the specific provider or of the service in general? There is no way to name all the accompanying risks---what are they wanting here.”
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12VAC35-109-80. ISP requirements.
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Section A “What about the individual’s preference? There are times the individual declines to have elements in their ISP that are health and safety and immediate needs”
Section A.1 “The word each is problematic. There may be needs identified that are outside scope of the service to address and individuals can choose not to address (dignity of risk); need to include documentation if person does not want to include”
Section A.2 “Frequency to accomplish may be beyond the scope of what can be authorized or what the person wants---Is this the ideal or the frequency of supports that the service will be provided and the person agrees too?”
Section A.4 “While possible to identify the service or agency for other aspects, it is unreasonable to be expect that employees of other agencies are identified in a services ISP.”
Section B.7
“Not all center-based services have to do a fall risk plan, yet this is written as though it is required.”
Section B.13 “Isn't the individuals self-directing all services in a person-centered service? What is meant by elects to self-direct?”
Section C.1 “This becomes another transactional task to be tracked."
Section E.2 “Training on the ISP and the importance of the ISP is valuable, but this whole section is an overreach and unrealistic to implement.”
“This is a documentation nightmare for "test." Competency is a word that is thrown around in this sentence and has lots of baggage--- Additionally, they should be responsible for knowledge of the aspects they are implementing, not each part of a person's full ISP.”
“Over-regulating and paternalistic. We are to test the providers' knowledge and/or competency on every objective and strategy contained within all ISP's and document in their personnel files? If taken literally, this would be so cumbersome to implement as to disrupt services.”
Section E.3 “‘Be made aware’ is an overreach, employees are responsible for reviewing the ISP to know of any changes.”
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12VAC35-109-90. Reassessments and ISP reviews.
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Section D “Are all other requirements n/a for meds only?”
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12VAC35-109-100.Progress notes or other documentation
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Section B.1 What does this mean? The information included in progress notes for different services may look different based goals and objectives of the service. Section B.6 “What is meant by clinical staff? Clinical is a word that causes confusion on what is meant. Suggest: Be signed and dated by staff or contractor qualified to provide the service.” |
12VAC35-109-110. Staffing
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Section A “For this section, with respect to defining who can supervise different services, the issues are the same as noted when providing service definitions. Does this line up with DMAS? What happens when they do not align?
Section I “Can the information state the staff must be the credentials of 12VAC35-109-210E? This would ensure that they line up if changed in other section of Virginia code.”
Section M.3 “This is new. Seems to state that access to medication is required to provide therapy. Recommend deleting this sentence”
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12VAC35-109-120. Health care policy.
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Section A.5 “Ethical consideration in having the results provided by a provider who cannot answer questions about the results. Omit this statement.” |
12VAC35-109-130. Emergency preparedness and response plan
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“Appreciate wanting providers to be prepared. This is very complex and challenging. The scope of this needs to be based on the service provided. Additionally, there is no way all of this can be done for each type of emergency. “
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12VAC35-109-140. Building inspection and classification.
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12VAC35-109-150. Physical environment. |
Section E “Find it interesting there is no upper limit to temperatures. There should be something about not having individuals in rooms higher than 85 or something around there.”
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12VAC35-109-160. Building and grounds. |
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12VAC35-109-170. Floor plan and building modifications. |
Section A “There needs to be an emergency clause so that updates can be submitted less than 45 days when needed. This timeline prevents providers from being able to adapt to needs of individuals.”
Section B “Renovations is a broadly used term and creates administrative burden. Does this mean when floors are replaced an application must be submitted? Suggest indicating statement of renovations which will change the size or dimensions of service areas.”
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12VAC35-109-180. Lighting. |
Section D “Each staff member has his/her own flashlight? Or enough available that clusters of staff can use the light from one shared flashlight?” |
12VAC35-109-190. Sewer and water inspections. |
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12VAC35-109-200. Standards for the evaluation of new licenses for providers of services to individuals with opioid addiction |
Section E.6 “Unrealistic staffing credentials especially in today's workforce shortage”
Section E.7 “Recommend deleting”
Section E.9 “Access to emergency care vs. Access to higher levels of care are not the same. Access to an ED is one thing. Access to IOP, PHP, CSU, or inpatient is unrealistic”
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12VAC35-109-230. Criteria for involuntary termination from treatment. |
" Though implied, this code does not explicitly state that it is for MAT programming only and is general enough to be misconstrued as being broader than MAT” |
12VAC35-109-260. Initial and periodic assessment services. |
Sections E This seems like too much for a provider to access especially if no payment”
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12VAC35-109-270. Special services for pregnant individuals. |
Section A “How is this feasible for self-pay individuals”
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12VAC35-109-280. Counseling sessions. |
“What is this? Counseling for what? What is counseling vs. Therapy? If in therapy, do we need to do counseling too?”
“Though implied, this code does not explicitly state that it is for MAT programming only and is general enough to be misconstrued as being broader than MAT” |
12VAC35-109-450. Substance abuse outpatient services admission criteria. |
“Concern of matching information and requirements in the DMAS ARTS manual. Not having them match creates many challenges for providers. Similar concern as mentioned regarding service definitions and staffing.” |
12VAC35-109-480. Mental health partial hospitalization program criteria. |
“Concern of matching information and requirements in the DMAS manual. Not having them match creates many challenges for providers. Similar concern as mentioned regarding service definitions and staffing.” |
12VAC35-109-80. ISP Requirements:
In Section A. regarding "Initial ISP", please consider revising language to include if the comprehensive ISP includes all elements of the initial ISP and is written in place of the initial ISP the "Initial ISP" is is not required. Requiring an initial ISP separate from a comprehensive ISP could be burdensome to the client and provider.
In Section E, 1-3. regarding documented training surrounding each individual's ISP w/ a test is an administrative burden to the provider and may encourage less revising of the ISP when we want to encourage revising the ISP when this is needed (we want to be client centered). Training surrounding ISP writing and implementation should be done at orientation and then at supervision level regularly.
12VAC35-120, 12VAC35-130, 12VAC35-180
Please consider revising language within these regulations as it appears to be heavily focused on residential treatment vs. "outpatient" center-based services. (i.e. 12 VAC35-120, Section A. 3 & 4, 12VAC35-130, Section 2b & 4c.)
Thank you for the opportunity to comment!
The Virginia Association of Community-Based Providers (VACBP) represents private-sector providers of behavioral health, substance use disorder and ABA services throughout the Commonwealth of Virginia. We appreciate the opportunity to share the following comments on the proposed regulations to the Center-Based Service chapter of the licensing regulations on behalf of our members. Below are some overarching comments that are reflected in the specific comments provided.
We propose the following specific changes in this section.
“Approved Accreditation Bodies”. The Department recognizes these accrediting bodies for licensed services. Agency proof of accreditation in good standing of the services under 12VAC35-109-20 substitutes for initial and periodic licensing inspections. Department inspection of agency locations as well as employee and client documentations requirements set forth in regulation is also not required for agencies with accredited services:
CARF International
6951 East Southpoint Road
Tucson, AZ 85756-9407
Council on Accreditation
45 Broadway, 29th Floor
New York, NY 10006
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
“Program sponsor” means the person(s) named in the application for licensing and shall have relevant training, experience, or both, in the treatment of individuals with opioid addiction.
"Qualified Mental Health Paraprofessional” of “QMHPP" means a person who must meet at least one of the following criteria: (i) registered with the United States Psychiatric Association (USPRA) as an Associate Psychiatric Rehabilitation Provider (APRP); (ii) has an associate's degree in a related field (social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services counseling) and at least one year of experience providing direct services to individuals with a diagnosis of mental illness; (iii) licensed as an occupational therapy assistant, and supervised by a licensed occupational therapist, with at least one year of experience providing direct services to individuals with a diagnosis of mental illness; or (iv) has a minimum of 90 hours classroom training and 12 weeks of experience under the direct personal supervision of a QMHP-A providing services to individuals with mental illness and at least one year of experience (including the 12 weeks of supervised experience).
The following outlines our comments in this section:
The following provides our input in this section:
The following outlines our input in this section:
The following outlines our input in this section:
The following outlines our input in this section:
The following outlines our input in this section:
The following outlines our input in this section:
The following outlines our input in this section:
For reasons consistent with our other comments, we suggest removing (2) of this section, which reads, “Ensure emergency services are available by telephone 24 hours a day, 7 days a week," given this is not a crisis-level service and being available in this way could be a significant challenge for providers. There are also liability and risk concerns related to this requirement among licensed mental health professionals.
The following outlines our input in this section:
Consistent with our previous comments, we suggest removing (3) of this section, which reads, “Provide emergency assistance 24 hours a day, 7 days a week,” given this is not a crisis-level service and being available in this way could be a significant challenge for providers. There are also liability and risk concerns related to this requirement among licensed mental health professionals.
Initial Draft NEW Center Based Service Chapter of the Licensing Regulations:
General statement: I agree with some previous comments about the clarification in these regulations regarding when ISP is referencing Parts I-V or just part V.
Definitions:
QDDP- the addition of the following statement is not consistent with what has been allowable, therefore, it could cause some that are in supervisory positions, to no longer qualify.
….if the person has five years of paid experience in providing direction, development, and implementation, direct supervision, and monitoring to the service provided. QDDPs are responsible for approving assessments and individual service plans or treatment plans to ensure appropriate services are provided to meet the needs of individuals receiving services. The QDDP shall have documented experience developing, conducting, and approving assessments and individual service plans or treatment plans.
12VAC35-109-70. Individualized services plan (ISP); Individualized supports plan; Service
planning.
supports, which is a component of the comprehensive individual support plan, 24
hours after admission.
This comment needs to be changed as we cannot submit this after 24 hours or there will be no payment. It is noted that we need submission of an ISP to WaMS 30 days in advance of the start date, so this statement does not make sense. In addition, the other regulations up for comment for Case Management notes the same, which has a large impact already on service providers being paid when case managers are given leeway in getting their documentation submitted timely as they are allowed to bill for services with other criteria, however, service providers cannot bill until the ISP is approved in WaMS causing us to lose payment when ISPs are not completed and pushed through for approval within WaMS prior to the start date of the ISP.
12VAC35-109-80. ISP Requirements
E. 2. After each training, providers shall test the employee’s or contractor’s knowledge,
competency, or both, and retain documentation of the test of the employee’s or
contractor’s knowledge, competency, or both within the employee or contractor’s
personnel file.
Please consider removing this requirement as this poses additional administrative burden and the DSP competency requirements already addresses having a working knowledge of the individuals for whom a DSP is working. In addition, the employee files should not contain information pertaining to an individual receiving services.
12VAC35-109-90. Reassessments and ISP reviews.
F. The provider shall complete quarterly reviews of the ISP in writing at least every three months from
the date of the implementation of the comprehensive ISP or whenever there is a reassessment. The review of the ISP shall be conducted in a person-centered manner, to determine if services are being delivered as described within the ISP. The individual receiving services and the authorized representative, if applicable, shall be included in the ISP review, to determine if the individual is satisfied with the services provided.
4. A review of the ISP shall note the:
a. Individual’s family involvement, if any, in the individual’s treatment;
It should not be the individual service provider’s responsibility to indicate family involvement in someone’s treatment. There is a review for satisfaction of service delivery that is reviewed quarterly when there is a Legal Guardian or Authorized Representative. Please provide clarification on this statement.
This proposed regulation is an unwarranted hardship for providers. Agencies will have to create a test for every individual served, test all staff members who work with that person, as well as having to track and file all the tests.
This is an excessive requirement, especially during a time providers are experiencing a workforce crisis that will not end soon.
The following outlines our input in this section:
The following outlines our input in this section:
The following outlines additional input in this section:
12VAC35-105-10 - recommendation to adding a definition for support decision making to this section
12VAC35-105-40 - recommendation changing medical condition to medical symptoms.
12VAC35-105-60 - add "and available" after if applicable
12VAC35-105-70 - A. #1 & #2 recommend changing 24 hour after admission to 1 business day
12VAC35-105-80 - While I agree employees should be knowledgeable about the contents of the ISP for individuals served, establishing expectations to train and test all employees involved in service delivery is an unrealistic expectation that will significantly distract from service delivery. Observations of knowledge and competency about providing the service is part of supervisory and performance evaluation. Moving forward with this is likely to reduce updates to ISPs. This places an undue burden on Human Resources and supervisors, who would have to develop ways to test and train employees while maintaining their other responsibilities.
12VAC35-105-90 - asking for clarification if quarterlies are required for this service.
12VAC35-105-100 -
B5. Clarification on what services would be beneficial such as outpatient but not day support. This is an impractical expectation for daily service documentation.
B6 - replace clinical staff to qualified staff
C - add informational notes along with communication logs and supervisory notes.
12VAC35-105-120 - A #3 & #4 - recommend to remove will provide as we cannot provide medical or dental services as we are not medical professionals.
12VAC35-105-130 - 2 b. remove as this pertains to residential services not centered based services
12VAC35-105-150 - recommendation to make consistent through DBHDS regulations. The temperature range is different for center based services than residential services.
12VAC35-105-200 - G. This is an impractical expectation for programs due to the administrative burden. This is not required for any other DBHDS licensed service, request this be removed.
The following outlines additional input in this section:
The following outlines input in this section:
The following outlines additional input in this section:
Dear DBHDS:
BrightView Health would like to express our appreciation for considering feedback from providers and making amendments that will allow us to better provide appropriate substance use disorder treatment services. BrightView concurs with the comments submitted by the Virginia Association of Medication Assisted Recovery Programs. Please find that BrightView submits the following additional comments.
12VAC35-109-250 Service Operation Schedule
Section B.2. States, "The provider receives prior approval from the state opioid treatment authority (SOTA) for Sunday closings. Each program must have a policy that addresses medication for the newly inducted patients and those who are deemed at risk, i.e., still actively using illicit substances or medical issues that may warrant closer monitoring of medication. This policy must include openings on Sundays for the population described above."
BrightView recommends changing the wording of the first sentence to read, "Provider will follow federal guidelines for Sunday closings."
12VAC35-109-280. Counseling sessions
Section A.1. States, "The provider shall conduct face-to-face counseling sessions (either individual, group, or family) of one hour minimum. The provider shall document details of each session including the length within the individual's service record. The counseling sessions shall occur: 1. Every week for the first six months of the first year of the individual's treatment."
BrightView recommends the counseling sessions are only required to be offered to the individual twice per month for the first twelve months of treatment.
Thank you for this opportunity to provide input on these proposed amendments. Please feel free to contact BrightView with any questions or if we can be of assistance in any way.
Thank you for considering these comments.
12VAC35-109-120. Health care policy. -
3. To what extent the provider will provide, arrange, or support the individual with the provision of medical and dental services identified at admission.
4. To what extent the provider will provide, arrange, or support the individual with the provision of routine ongoing and follow-up medical and dental services after admission.
5. How the provider will communicate the results of any physical examinations, medical assessments, and any diagnostic tests, treatments, or examinations to the individual and authorized representative, as appropriate.
6. How the provider will keep accessible to staff and contractors on duty the names, addresses, and phone numbers of the individual's medical and dental providers.
7. To what extent the provider will ensure a means for facilitating and arranging, as appropriate, transportation to medical and dental appointments and medical tests.
The overall policy is directed at Center Based services. Center based day support services will not likely have any control of nor should they for items 3 through 7. I recommend that these references be clarified as to what actual services they are required (IE opioid treatment centers, Center Based Respite, etc).