Section 22 VAC 40-61-90 F provides that incident reports are to be included in the participant's record.  In health care facilities these are normally business records.  As the incident pertains to a participant, a note is made in the participant's chart.  This is the better practice. The IR may include information about other participants or other persons that is not necessary and would not be appropriately shared.

I recommend that 22 VAC 40-61-90 F be stricken from the regulation.

Cheryl Flowers, Manager, Loudoun County Adult Day Center-Leesburg

Reports of abuse, neglect, and exploitation should never jeopardize the participant. Notifying the participant's contact person is putting that participant, as well as the reporter in jeopardy, especially if the contact person is the abuser. I recommend that 22VAC40-61-110 B. be stricken from the regulation.

Recommendations for Adult Day Care regulations.

Submitted by:

Carla C. Groff

Bedford Adult Day Center

1617 Oakwood Street

Bedford, VA 24523

Phone: 540-586-8424

10/22/2019

22VAC 40-61-330 Part D: Activities.

Comment:

Current regulations have no requirement for a “designated staff person” responsible for activities. Adding the requirement for a “designated” activity staff will create hardship on providers from a financial perspective as well as a staffing perspective.

The proposed regulations on who can meet the qualifications as a “designated” activities staff person are too restrictive from an educational as well as experiential perspective. The requirements will be difficult for facilities to meet from a budgetary standpoint as well the standpoint of securing qualified staff.

1. According to the Bureau of Labor Statistics, a therapeutic recreation specialist has annual wages of $45,890, an occupational therapist has annual wages of $80,150, and an occupational therapy assistant has annual wages of $57,870. ADHC facilities who serve publicly funded individuals would be unable to sustain these wages on the current all-inclusive Medicaid reimbursement rate of $57.04 per day which amounts to an hourly rate of $5.70 for centers what are open 10 hours per day.
2. The option to utilize a qualified activities professional is not only expensive, but the training is difficult to obtain for employees in rural communities. According to the Virginia Health Care Association website, the activities professional course is only offered in a week-long once yearly course with a training fee of $695. It would require applicants to travel and make overnight accommodations.
3. The requirement for having at least an Associates degree in” a discipline focusing on the provision of activities for adults” is unclear. (Section D4).
4. The requirement for 1-year experience in an activities program in an adult care setting   would also be difficult to meet in small communities that only support 1 or 2 long term care settings.

5. Assisted Living regulations also have an option for 40-hour department-approved activities training.  This would also be a good option for ADHC

    

   Recommendation:

    The proposed regulations 22VAC10-61-330 Activities, Part D should either be eliminated in its entirety or changed as follows.

22VAC10-61-330 Activities, Part D

1. Be a qualified therapeutic recreation specialist, activities professional, or related creative arts specialist, or related health care clinician.

2. Be eligible for certification as a therapeutic recreation specialist, activities professional or related creative arts specialist, or related health care clinician.

3.No change.

4. Have a least an Associates degree in a human service, health care, education, physical education, humanities, psychology, social sciences, social work, disability studies, fine arts, or related field.

5.Have one-year full-time experience within the last five years in a health care or disability services program. (omit activities program). or

6. Prior to or within six months or employment, have successfully completed 40 hours of department-approved training in adult group activities and in recognizing and assessing the activity needs of participant.

22VAC 40-61-160. First Aid and CPR certification.

Part A. First Aid.

Comment:    This regulation is contradictory.

Recommendation: The regulation should read as follows:

1. There shall be at least one direct care staff member on premises at all times who has current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.  The certification must either be in adult first aid or include adult first aid. To be considered current, the certification shall have been issued win the past three years.
2. A direct care staff member who is a registered nurse or licensed practical nurse does not have to meet the requirements of subdivisions 1 and 2 of this subsection.

22VAC40-61-1: Definitions:

Comment:

To clarify who would count as direct care staff, and who would need direct care staff training, the definition of “Direct Care Staff” needs clarification.

Recommendation:

“Direct Care Staff” means supervisors, assistants, aides, or other staff of a center who assist participants win the performance of personal care or ADLS and are counted in the staff to participant ratio.

Respectfully Submitted:

Carla C. Groff

Participant Rights and Responsibilities.  F.  Rights and Responsibilities understanding determined on the Physician's Report Form. 

The Physician does not have a copy of the Rights and Responsibilities of the Center.  Perhaps a general statment such as :  This person is able/ unable (circle one) to fully comprehend written statements concerning personal welfare.

Reports of Abuse and Neglect.  Take out B - notifying contact person or legal respresentative.

While offering the clarifier "unless such notification would jeopardize the participant", I believe this would be an automatic and therefore toally unnecessary.

Participant Agreement with Center.  2.. Financial Agreement.  B. Amount and purpose of advance payment, D.  Return policy if Center closes.

This is internal business and should be monitored by a Center's governing body, not a regulation through licensing.

A. Specific Methods and timeframes to monitor infection practices by staff and volunteers"

We are not clear as to what this actually means.  Needs clarity.

Assistance with ADLS  B.  Assistance with eating and feeding.  #5 "Low-stimulus dining area" 

Is this suggesting a separate dining area?  How will this be regulated as necessary?

C.  A Professional RT or OT, a person with one year of experience in Activities.

What is the accrediting body for determining "Activity Professional"?  

This regulation seems restrictive in that it offers no opportunity to hire and train and quality person without the correct experience.  This can be very difficult for regions where the employee pool is limited.

For those near a University, it  fails to allow the hiring of a music therapist right out of college, and it appears a 6-month internship with the Site even would not qualify the candidate.

22VAC 40-61-330 Part D: Activities.

Comment:

Current regulations have no requirement for a “designated staff person” responsible for activities. Adding the requirement for a “designated” activity staff will create hardship on providers from a financial perspective as well as a staffing perspective.

The proposed regulations on who can meet the qualifications as a “designated” activities staff person are too restrictive from an educational as well as experiential perspective. The requirements will be difficult for facilities to meet from a budgetary standpoint as well the standpoint of securing qualified staff.

1. According to the Bureau of Labor Statistics, a therapeutic recreation specialist has annual wages of $45,890, an occupational therapist has annual wages of $80,150, and an occupational therapy assistant has annual wages of $57,870. ADHC facilities who serve publicly funded individuals would be unable to sustain these wages on the current all-inclusive Medicaid reimbursement rate of $57.04 per day which amounts to an hourly rate of $5.70 for centers what are open 10 hours per day.
2. The option to utilize a qualified activities professional is not only expensive, but the training is difficult to obtain for employees in rural communities. According to the Virginia Health Care Association website, the activities professional course is only offered in a week-long once yearly course with a training fee of $695. It would require applicants to travel and make overnight accommodations.
3. The requirement for having at least an Associates degree in” a discipline focusing on the provision of activities for adults” is unclear. (Section D4).
4. The requirement for 1-year experience in an activities program in an adult care setting   would also be difficult to meet in small communities that only support 1 or 2 long term care settings.

5. Assisted Living regulations also have an option for 40-hour department-approved activities training.  This would also be a good option for ADHC

    

   Recommendation:

    The proposed regulations 22VAC10-61-330 Activities, Part D should either be eliminated in its entirety or changed as follows.

22VAC10-61-330 Activities, Part D

1. Be a qualified therapeutic recreation specialist, activities professional, or related creative arts specialist, or related health care clinician.

2. Be eligible for certification as a therapeutic recreation specialist, activities professional or related creative arts specialist, or related health care clinician.

3.No change.

4. Have a least an Associates degree in a human service, health care, education, physical education, humanities, psychology, social sciences, social work, disability studies, fine arts, or related field.

5.Have one-year full-time experience within the last five years in a health care or disability services program. (omit activities program). or

6. Prior to or within six months or employment, have successfully completed 40 hours of department-approved training in adult group activities and in recognizing and assessing the activity needs of participant.

22VAC 40-61-160. First Aid and CPR certification.

Part A. First Aid.

Comment:    This regulation is contradictory.

Recommendation: The regulation should read as follows:

1. There shall be at least one direct care staff member on premises at all times who has current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.  The certification must either be in adult first aid or include adult first aid. To be considered current, the certification shall have been issued win the past three years.
2. A direct care staff member who is a registered nurse or licensed practical nurse does not have to meet the requirements of subdivisions 1 and 2 of this subsection.

22VAC40-61-1: Definitions:

Comment:

To clarify who would count as direct care staff, and who would need direct care staff training, the definition of “Direct Care Staff” needs clarification.

Recommendation:

“Direct Care Staff” means supervisors, assistants, aides, or other staff of a center who assist participants win the performance of personal care or ADLS and are counted in the staff to participant ratio.

22VAC 40-61-330 Part D: Activities

Comment:

Current regulations have no requirement for a “designated staff person” responsible for activities. Adding the requirement for a “designated” activity staff will create hardship on providers from a financial perspective as well as a staffing perspective.

The proposed regulations on who can meet the qualifications as a “designated” activities staff person are too restrictive from an educational as well as experiential perspective. The requirements will be difficult for facilities to meet from a budgetary standpoint as well the standpoint of securing qualified staff.

1. According to the Bureau of Labor Statistics, a therapeutic recreation specialist has annual wages of $45,890, an occupational therapist has annual wages of $80,150, and an occupational therapy assistant has annual wages of $57,870. ADHC facilities who serve publicly funded individuals would be unable to sustain these wages on the current all-inclusive Medicaid reimbursement rate of $57.04 per day which amounts to an hourly rate of $5.70 for centers what are open 10 hours per day.
2. The option to utilize a qualified activities professional is not only expensive, but the training is difficult to obtain for employees in rural communities. According to the Virginia Health Care Association website, the activities professional course is only offered in a week-long once yearly course with a training fee of $695. It would require applicants to travel and make overnight accommodations.
3. The requirement for having at least an Associates degree in” a discipline focusing on the provision of activities for adults” is unclear. (Section D4).
4. The requirement for 1-year experience in an activities program in an adult care setting   would also be difficult to meet in small communities that only support 1 or 2 long term care settings.

5. Assisted Living regulations also have an option for 40-hour department-approved activities training.  This would also be a good option for ADHC

    

   Recommendation:

    The proposed regulations 22VAC10-61-330 Activities, Part D should either be eliminated in its entirety or changed as follows:

22VAC10-61-330 Activities, Part D

1. Be a qualified therapeutic recreation specialist, activities professional, or related creative arts specialist, or related health care clinician.

2. Be eligible for certification as a therapeutic recreation specialist, activities professional or related creative arts specialist, or related health care clinician.

3.No change.

4. Have a least an Associates degree in a human service, health care, education, physical education, humanities, psychology, social sciences, social work, disability studies, fine arts, or related field.

5.Have one-year full-time experience within the last five years in a health care or disability services program. (omit activities program). or

6. Prior to or within six months or employment, have successfully completed 40 hours of department-approved training in adult group activities and in recognizing and assessing the activity needs of participant.

Comment

Current regulations have no requirement for a "designated staff person" responsible for activities. Adding the requirement for a "designated" activity staff will create a financial hardship on providers, especially those centers located in rural areas.

The regulations are the minimum requirements for adult day services and for the regulations to change to a "designated" activities staff person are too restrictive from an educational as well as experiential perspective. The requirements will be difficult from a budgetary perspective, especially with government-supported programs reimbursement rate being substantially under the true cost of care. 

1. According to the Bureau of Labor Statistics, a therapeutic recreation specialist has annual wages of $45,890, an Occupational Therapist has annual wages of $80,150 and an Occupational Therapy Assistant has annual wages of $57,870. All are before fringe benefits. ADHC facilities who serve publicly funded programs will not be able to pay those wages and be sustainable when couple with the other staffing requirements. The current rate of reimbursement in the Medicaid waiver, Commonwealth Coordinated Care Plus (CCC+), is $57.04 for most of Virginia. The average cost of care across the state is over $100 per day.
2. The option to utilize a qualified activities professional is only expensive, but the training is difficult to obtain for employees in rural areas of the state. The activities professional course through the National Certification Council for Activity Professionals is a 40-hour training course for $695. This does not include the staff coverage that would be needed in the center and the extra cost the center would have to support. This training program may not be only offered through NCCAP in the future and this regulation does not allow enough variance to include future developments. 
3. The requirement for having at least an Associate's degree in "a discipline focusing on the provision of activities for adults" is vague.
4. The requirement for 1-year experience in an activities program in an adult care setting would be difficult for those in rural areas where the ADHC is only in the area. 

Recommendation:

The proposed regulation 22VAC40-61-330 Activities, Part D should either be eliminted in its entirety or changed to include other therapies like music and art therapy professionals.

The proposed regulation should either be eliminated or revised to be a minimal standard that does not create a financial hardship, especially for small centers or those in rural areas. 

The proposed regulation should either be eliminated or revised to include any current or future training program offered through National Certification Council for Activity Professionals. 

The proposed regulation should either be eliminated or revised to include 1-year experience in an adult day setting or long-term care setting. 

Part A. First Aid

This regulation is contradictory and should be revised.

1. There shall be at least one direct care staff member on premises at all times who has current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. To be considered current, the certification shall have been issued within the past three years.
2. A direct care staff member who is a registered nurse or licensed practical nurse does not have to meet the requirements of subdivisions 1 and 2 of this subsection.

Recommendation:

"Direct Care Staff" means supervisors, assistants, aides, and other staff of a center assist participants with the performance of personal care or ADLs and are counted in the staff to participant ratio.

22 VAC 40-61-330 Part D Activities:

Comment:  Existing regulations have no stipulation for a "designated staff person" assigned to activities.  Adding the requirement for a "designated" activity staff will create an extreme hardship of financial and staffing challenges.

Proposed regulations on who can qualify as a "designated" activities staff person are too confining from an educational point of view.  It will be challenging to secure the qualified staff person and be hardship to the facilities budget.

CTRS according to Bureau of Labor Statistics garners annual wages of $45,890,  These wages are exorbitant for centers who are publicly funded with LOA and EDCD Medicaid Waiver.  The Medcaid reimbursement rate is $57.04 per day which equals an hourly rate of $5.19 for our center which is open 11 hours per day.

CTRS training is difficult to access in Southwest Virginia and rural communities.  The Activity Director's course via the Virginia Health Care Association is only offered in a week-long yearly course with a fee of $695.  Applicants would incur travel expenses, meals, and overnight accomodations.

Requirement for having at least an Associate Degree in "a discipline focusing on provision of activities for adults" needs to be clarified (Section D4).

Requirement for 1-yr experience in an activities program in an adult care setting would be challenging to meet in smaller communities that support 1 or 2 long-term care settings.

Assisted Living regulations have an option for 40-hour department-approved activities training.  This would be an excellent choice for Adult Day Care Centers.

Recommendation:  The proposed regulations 22 VAC10-61-330 Activities, Part D should either be eliminated or amended as follows:

22VAC10-61-330 Activities, Part D

1.  Be a qualified therapeutic recreation specialist, activities professional, or related field in recreation, creative arts specialist, or related health care clinician.

2. Be eligible for certification as a therapeutic recreation specialist, activities professional or related field in recreation, creative arts specialist, or related health care clinician.

3. No change

4. Have at least an Associates degree in human service, health care, education physical education, recreation, humanities, psychology, social sciences, social work, disability studies, fine arts or a related field.

5. Have one-year full-time experience within the last 5 years in a health care or disability services program (omit activities program) or

6. Prior to or within 6 months or employment, have successfully completed 40 hours of department-approved training in adult group activities and in recognizing and assessing the activity needs of participants.

22VAC40-61-160.  First Aid and CPR Certification.

Part A First Aid

Comment:  This regulation is confusing and conflicting.

Recommendation:  The regulation should read as follows:

1.  There shall be at least one direct care staff member on premises at all times who has current certification in first aid from:  American Red Cross, American Hearth Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire dept.  The certification must be in adult first aid or include adult first aid. To be considered current, the certification shall have been issued within the past 3 years.

2.  A direct care staff member who is a registered nurse or licensed practical nurse doesn't have to meet the requirements of subdivisions 1 and 2 of this subsection.

22VAC40-61-1 Definitions:

Comment:  Clarification is needed to see who would count as direct care staff and who would need direct care staff training,

Recommendation:  "Direct Care Staff" means supervisors, assistants, aides, or other staff of a center who assist participants with the performance of personal care or ADLs and counted in the staff to participant ratio.

This regulation is misleading. Centers may maintain information on the full incident and those are typically called incident reports. The reports have all information surrounding an incident and cannot be kept in a participant's chart as the report may contain private information regarding another participant or other person. A note by a staff member is filed in the chart pertaining to the participant. 

Recommendation:

This regulation be removed in its entirety. 

Comment:

The proposed regulation reads, "The Center shall notify [the participant and] the participant's contact person or legal representative when a report is made as referenced in subsection A of this section, without identifying any confidential information [unless such notification would jeopardize the participant]. 

All healthcare employees are mandated reporters. This regulation has the potential to put both the participant and center staff in danger. One of the healthcare worker's protection when reporting is that the report can be made anonymously. This regulation takes away that protection. 

Recommendation:

Remove 22VAC40-61-120 B. from the regulation. 

Comment:

Regulation reads that "a participant shall be assumed capable of understanding and exercising these rights and responsibilities unless a physician determines otherwise and documentation is contained in the participant's record."

The physician assesses for general orientation, not for understanding and exercising these rights and responsibilities. The center staff interact with the participant significantly more than the physician and would have a more accurate assessment of capabilities. Orientation and ability to understand and exercise rights can change drastically in between physician visits. 

Recommendation:

Remove this regulation.

Comment:

Regulation 240 2b. requires centers to have policies regarding the amount and purpose of advancement payment.

d. requires the center to have a refund policy to apply to transfer of ownership, closing of center. or participant discharge occurs. 

These issues are business issues and should not be regulated by a licensing body.

Recommendation:

Remove b. and change d. to requiring a refund policy without specifics.

Recommendations for Adult Day Care Center regulations. 

22VAC 40-61-330 Part D: Activities. 

Comment: 

Current regulations have no requirement for a “designated staff person” responsible for activities. Adding the requirement for a “designated” activity staff will create hardship on providers from a financial perspective as well as a staffing perspective. 

The proposed regulations on who can meet the qualifications as a “designated” activities staff person are too restrictive from an educational as well as experiential perspective. The requirements will be difficult for facilities to meet from a budgetary standpoint as well the standpoint of securing qualified staff. 

1. According to the Bureau of Labor Statistics, a therapeutic recreation specialist has annual wages of $45,890, an occupational therapist has annual wages of $80,150, and an occupational therapy assistant has annual wages of $57,870. ADHC facilities who serve publicly funded individuals would be unable to sustain these wages on the current all-inclusive Medicaid reimbursement rate of $57.04 per day which amounts to an hourly rate of $5.70 for centers what are open 10 hours per day. 

2. The option to utilize a qualified activities professional is not only expensive, but the training is difficult to obtain for employees in rural communities. According to the Virginia Health Care Association website, the activities professional course is only offered in a week-long once yearly course with a training fee of $695. It would require applicants to travel and make overnight accommodations.

3. The requirement for having at least an Associates degree in” a discipline focusing on the provision of activities for adults” is unclear. (Section D4).

4. The requirement for 1-year experience in an activities program in an adult care setting   would also be difficult to meet in small communities that only support 1 or 2 long term care settings.

5. Assisted Living regulations also have an option for 40-hour department-approved activities training.  This would also be a good option for ADHC

Recommendation: 

 The proposed regulations 22VAC10-61-330 Activities, Part D should either be eliminated in its entirety or changed as follows.

22VAC10-61-330 Activities, Part D

1. Be a qualified therapeutic recreation specialist, activities professional, or related creative arts specialist, or related health care clinician.

2. Be eligible for certification as a therapeutic recreation specialist, activities professional or related creative arts specialist, or related health care clinician.

3.No change.

4. Have a least an Associates degree in a human service, health care, education, physical education, humanities, psychology, social sciences, social work, disability studies, fine arts, or related field.

5.Have one-year full-time experience within the last five years in a health care or disability services program. (omit activities program). or

6. Prior to or within six months or employment, have successfully completed 40 hours of department-approved training in adult group activities and in recognizing and assessing the activity needs of participant.

22VAC 40-61-160. First Aid and CPR certification. 

Part A. First Aid.

Comment:  This regulation is contradictory. 

Recommendation: The regulation should read as follows:

1. There shall be at least one direct care staff member on premises at all times who has current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.  The certification must either be in adult first aid or include adult first aid. To be considered current, the certification shall have been issued win the past three years.

2. A direct care staff member who is a registered nurse or licensed practical nurse does not have to meet the requirements of subdivisions 1 and 2 of this subsection.

22VAC40-61-1: Definitions:

Comment: 

To clarify who would count as direct care staff, and who would need direct care staff training, the definition of “Direct Care Staff” needs clarification.

Recommendation: 

“Direct Care Staff” means supervisors, assistants, aides, or other staff of a center who assist participants win the performance of personal care or ADLS and are counted in the staff to participant ratio.

Current regulations have no requirements for a "designated staff person" responsible for activities.  Adding the requirement for a "designated" activity staff will create a financial hardship to providers, especially those centers in rural areas.

The proposed regulation reads, "The Center shall notify [the participant and] the participant's contact person or legal representative when a report is made as referenced in subsection A of this section, without identifying any confidential information [unless such notification would jeopardize the participant]. 

All healthcare employees are mandated reporters. This regulation has the potential to put both the participant and center staff in danger. One of the healthcare worker's protection when reporting is that the report can be made anonymously. This regulation takes away that protection. 

Recommend : remove this requirement

Current regulations have no requirement for a "designated staff person" responsible for activities.  Adding the requirement for a "designated" activity staff will create an extreme hardship on my center, as well as many others.  We are a new center, and creating the requirement will create a nightmare for our budget.  Also - we feel it is not necessary to have a distinct person, as all of our staff serve as "activity people", in that we provide person-centered care to all by cross-training our staff - even our CNA's.  

We feel this proposed regulation should be eliminated.  

22VAC 40-61-330 Part D: Activities

Comment:

Current regulations have no requirement for a “designated staff person” responsible for activities. Adding the requirement for a “designated” activity staff will create hardship on providers from a financial perspective as well as a staffing perspective.

The proposed regulations on who can meet the qualifications as a “designated” activities staff person are too restrictive from an educational as well as experiential perspective. The requirements will be difficult for facilities to meet from a budgetary standpoint as well the standpoint of securing qualified staff.

1. According to the Bureau of Labor Statistics, a therapeutic recreation specialist has annual wages of $45,890, an occupational therapist has annual wages of $80,150, and an occupational therapy assistant has annual wages of $57,870. ADHC facilities who serve publicly funded individuals would be unable to sustain these wages on the current all-inclusive Medicaid reimbursement rate of $57.04 per day which amounts to an hourly rate of $5.70 for centers what are open 10 hours per day.
2. The option to utilize a qualified activities professional is not only expensive, but the training is difficult to obtain for employees in rural communities. According to the Virginia Health Care Association website, the activities professional course is only offered in a week-long once yearly course with a training fee of $695. It would require applicants to travel and make overnight accommodations.
3. The requirement for having at least an Associates degree in” a discipline focusing on the provision of activities for adults” is unclear. (Section D4).
4. The requirement for 1-year experience in an activities program in an adult care setting   would also be difficult to meet in small communities that only support 1 or 2 long term care settings.

5. Assisted Living regulations also have an option for 40-hour department-approved activities training.  This would also be a good option for ADHC

   Recommendation:

    The proposed regulations 22VAC10-61-330 Activities, Part D should either be eliminated in its entirety or changed as follows:

22VAC10-61-330 Activities, Part D

1. Be a qualified therapeutic recreation specialist, activities professional, or related creative arts specialist, or related health care clinician.

2. Be eligible for certification as a therapeutic recreation specialist, activities professional or related creative arts specialist, or related health care clinician.

3.No change.

4. Have a least an Associates degree in a human service, health care, education, physical education, humanities, psychology, social sciences, social work, disability studies, fine arts, or related field.

5.Have one-year full-time experience within the last five years in a health care or disability services program. (omit activities program). or

6. Prior to or within six months or employment, have successfully completed 40 hours of department-approved training in adult group activities and in recognizing and assessing the activity needs of participant.

Comment:

Regulation reads that "a participant shall be assumed capable of understanding and exercising these rights and responsibilities unless a physician determines otherwise and documentation is contained in the participant's record."

The physician assesses for general orientation, not for understanding and exercising these rights and responsibilities. The center staff interact with the participant significantly more than the physician and would have a more accurate assessment of capabilities. Orientation and ability to understand and exercise rights can change drastically in between physician visits. 

Recommendation:

Remove this regulation.

Reports of abuse, neglect, and exploitation should never jeopardize the participant. Notifying the participant's contact person is putting that participant, as well as the reporter in jeopardy, especially if the contact person is the abuser.

I recommend that 22VAC40-61-110 B. be stricken from the regulation..

Part B should be deleted. Center's should be allowed to decide on a case-by-case basis whether contacting the legal representative is prudent. Mandated reporters should be protected by confidentiality laws. This regulation would be especially troublesome when the legal representative is the subject of the complaint. Jeopardizing the participant is not the only concern here.

Please delete section F. The report should be filed in a separate location, not in the participant's record.

Please delete section F. The facility staff and family caregivers have more frequent and extensive contact with the participant and would be better equipped to determine the participant's capability to understand their rights.

22VAC 40-61-330 Part D: Activities.

Current regulations have no requirement for a “designated staff person” responsible for activities. Adding the requirement for a “designated” activity staff will create hardship on providers from a financial perspective as well as a staffing perspective.

The proposed regulations on who can meet the qualifications as a “designated” activities staff person are too restrictive from an educational as well as experiential perspective. The requirements will be difficult for facilities to meet from a budgetary standpoint as well the standpoint of securing qualified staff.

1. According to the Bureau of Labor Statistics, a therapeutic recreation specialist has annual wages of $45,890, an occupational therapist has annual wages of $80,150, and an occupational therapy assistant has annual wages of $57,870. ADHC facilities who serve publicly funded individuals would be unable to sustain these wages on the current all-inclusive Medicaid reimbursement rate of $57.04 per day which amounts to an hourly rate of $5.70 for centers what are open 10 hours per day.
2. The option to utilize a qualified activities professional is not only expensive, but the training is difficult to obtain for employees in rural communities. According to the Virginia Health Care Association website, the activities professional course is only offered in a week-long once yearly course with a training fee of $695. It would require applicants to travel and make overnight accommodations.
3. The requirement for having at least an Associates degree in” a discipline focusing on the provision of activities for adults” is unclear. (Section D4).
4. The requirement for 1-year experience in an activities program in an adult care setting   would also be difficult to meet in small communities that only support 1 or 2 long term care settings.
5. Assisted Living regulations also have an option for 40-hour department-approved activities training.  This would also be a good option for ADHC

Recommendation:

 The proposed regulations 22VAC10-61-330 Activities, Part D should either be eliminated in its entirety or changed as follows.

22VAC10-61-330 Activities, Part D

1. Be a qualified therapeutic recreation specialist, activities professional, or related creative arts specialist, or related health care clinician.

2. Be eligible for certification as a therapeutic recreation specialist, activities professional or related creative arts specialist, or related health care clinician.

3.No change.

4. Have a least an Associates degree in a human service, health care, education, physical education, humanities, psychology, social sciences, social work, disability studies, fine arts, or related field.

5.Have one-year full-time experience within the last five years in a health care or disability services program. (omit activities program). or

6. Prior to or within six months or employment, have successfully completed 40 hours of department-approved training in adult group activities and in recognizing and assessing the activity needs of participant.

What is the accrediting body for determining "Activity Professional"?  

This regulation seems restrictive in that it offers no opportunity to hire and train a quality person without the correct experience.  This can be very difficult and cost-prohibitive for regions where the employee pool is limited.

22 VAC 40-61-310 says The use of chemical or physical restraints is prohibited. 

Question:  What is the position of a Center RN when an MD or other prescriber orders a potentially or intentionally sedating medication.  What if a person applies for admission and is on that type of medication.  Can they be served if the medication needs to be administered at the Center?   

Section 22VAC40-61-90F provides that all incident reports are to be maintained in the participant's record.  In health care facilities these are normally business records.  As the incident pertains to a participant, a note is made in the participant's chart.  This is the better practice. The incident report may include information about other participants or other persons that is not necessary and would not be appropriately shared.

I recommend that 22VAC40-61-90F be stricken from the regulation.

I agree with Glenette and Laurie Deaver's comments from Generations Crossing in Harrisonburg, VA.

22 VAC 40-61-330 D 3  Allows a qualified occupational therapist or an occupational therapy assistant to be the activity director.  Both of those must be licensed by the Board of Medicine to practice in Virginia and the COTA (occupational therapy assistant) must be supervised by the OTR (qualified occupational therapist).  If a COTA was the Activity Director there would need to be an OTR supervisor.  This might need to be explored with the Licensing Board as to how much supervision.  It does not seem to be much of a solution for those in smaller towns where health care employees are scarce anyway to allow own that is already in demand.  Compensation is also an issue as noted in other comments.

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22 VAC 40-61-270 C.  If a participant fails to pay for care for 30 days, must they be given another 30 days before being discharged if they continue to not pay or have a plan negotiated to pay.

With the regulation written the way it is- it will be difficult to meet the minimum requirements of an activity professional for ADC programs in the rural parts of the state.  Please consider the following suggested changes:

1.Be a qualified therapeutic recreation specialist, activities professional, or related creative arts specialist, or related health care clinician.

2. Be eligible for certification as a therapeutic recreation specialist, activities professional or related creative arts specialist, or related health care clinician.

4. Have a least an Associates degree in a human service, health care, education, physical education, humanities, psychology, social sciences, social work, disability studies, fine arts, or related field.

22 VAC 40-61-90  "Major incident" needs to be made more clear.  What is the purpose of this regulation?  It does not appear that there is any response required by Licensing which should be included if there is so Centers know the full process.  

Part A. First Aid.

Comment:    This regulation is contradictory.

Recommendation: The regulation should read as follows:

1. There shall be at least one direct care staff member on premises at all times who has current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.  The certification must either be in adult first aid or include adult first aid. To be considered current, the certification shall have been issued win the past three years.
2. A direct care staff member who is a registered nurse or licensed practical nurse does not have to meet the requirements of subdivisions 1 and 2 of this subsection.

Define "major":

A. Each center shall report to the regional licensing office within 24 hours of the occurrence of any major  incident that incident that has negatively affected or that threatens the life, health, safety, or welfare of any participant.

Accidents due to falls, cuts, arguments resulting in injury, or a pt wandering out are incident report worthy.  Does an incident report need to be done if it was health related, like a stroke or heart attach?  For non "accident" related incidents, a progress note would suffice- unless these are considered major.

F. All reports [ pertaining specifically to a participant, ] such as but not limited to, adult protective services, medical, or police, shall be maintained in the participant's record.

The center shall notify [ the participant and ] the participant's contact person or legal representative when a report is made as referenced in subsection A of this section, without identifying any confidential information [ unless such notification would jeopardize the participant].

As mandated reporters, we are not expected to notify families that we made a report.  Although it seems this is covered with "unless such notification would jeopardize the participant," this may prevent people from feeling safe to report.

Current regulations have no requirement for a “designated staff person” responsible for activities. Adding the requirement for a “designated” activity staff will create hardship on providers from a financial perspective as well as a staffing perspective.

The proposed regulations on who can meet the qualifications as a “designated” activities staff person are too restrictive from an educational as well as experiential perspective. The requirements will be difficult for facilities to meet from a budgetary standpoint as well the standpoint of securing qualified staff.

1. According to the Bureau of Labor Statistics, a therapeutic recreation specialist has annual wages of $45,890, an occupational therapist has annual wages of $80,150, and an occupational therapy assistant has annual wages of $57,870. ADHC facilities who serve publicly funded individuals would be unable to sustain these wages on the current all-inclusive Medicaid reimbursement rate of $57.04 per day which amounts to an hourly rate of $5.70 for centers what are open 10 hours per day.
2. The option to utilize a qualified activities professional is not only expensive, but the training is difficult to obtain for employees in rural communities. According to the Virginia Health Care Association website, the activities professional course is only offered in a week-long once yearly course with a training fee of $695. It would require applicants to travel and make overnight accommodations.
3. The requirement for having at least an Associates degree in” a discipline focusing on the provision of activities for adults” is unclear. (Section D4).
4. The requirement for 1-year experience in an activities program in an adult care setting   would also be difficult to meet in small communities that only support 1 or 2 long term care settings.
5. Assisted Living regulations also have an option for 40-hour department-approved activities training.  This would also be a good option for ADHC

Recommendation:

 The proposed regulations 22VAC10-61-330 Activities, Part D should either be eliminated in its entirety or changed as follows.

22VAC10-61-330 Activities, Part D

1. Be a qualified therapeutic recreation specialist, activities professional, or related creative arts specialist, or related health care clinician.

2. Be eligible for certification as a therapeutic recreation specialist, activities professional or related creative arts specialist, or related health care clinician.

3.No change.

4. Have a least an Associates degree in a human service, health care, education, physical education, humanities, psychology, social sciences, social work, disability studies, fine arts, or related field.

5.Have one-year full-time experience within the last five years in a health care or disability services program. (omit activities program). or

6. Prior to or within six months or employment, have successfully completed 40 hours of department-approved training in adult group activities and in recognizing and assessing the activity needs of participant.

Reports of abuse, neglect, and exploitation should never jeopardize the participant. Notifying the participant's contact person is putting that participant, as well as the reporter in jeopardy, especially if the contact person is the abuser. I recommend that 22VAC40-61-110 B. be stricken from the regulation.

Please delete section F of the participants rights and responsibilities. The facility staff and family caregivers have more frequent and extensive contact with the participant and would be better equipped to determine the participant's capability to understand their rights. 

Regulation reads that "a participant shall be assumed capable of understanding and exercising these rights and responsibilities unless a physician determines otherwise and documentation is contained in the participant's record."

The physician assesses for general orientation, not for understanding and exercising these rights and responsibilities. The center staff interact with the participant significantly more than the physician and would have a more accurate assessment of capabilities. Orientation and ability to understand and exercise rights can change drastically in between physician visits. 

Recommendation: Remove this regulation.

Current regulations have no requirement for a "designated staff person" responsible for activities.  Adding the requirement for a "designated" activity staff will create an extreme hardship on smaller centers. It is not necessary to have a distinct person, especially at the pay rate of an Occupational Therapist, as all of our staff, for instance, serve as "activity" staff.

This regulation also offers no opportunity to hire and train quality people without the “correct” educational background.

Recommendation:

The proposed regulation 22VAC40-61-330 Activities, Part D should either be eliminated in its entirety or changed to be a minimal standard that does not create a financial hardship, especially for small centers or those in rural areas. 

The proposed regulation should either be eliminated or revised to include any current or future training program offered through National Certification Council for Activity Professionals. 

The proposed regulation should either be eliminated or revised to include 1-year experience in an adult day setting or long-term care setting.

The proposed regulation reads, "The Center shall notify [the participant and] the participant's contact person or legal representative when a report is made as referenced in subsection A of this section, without identifying any confidential information [unless such notification would jeopardize the participant]."

All healthcare employees are mandated reporters. This regulation has the potential to put both the participant and Center staff in danger. One of the healthcare worker's protections when reporting is that the report can be made anonymously. This regulation takes away that protection. 

Recommendation:

Remove 22VAC40-61-120 B. from the regulation. 

This regulation is misleading. Centers may maintain information on the full incident and those are typically called incident reports. The reports have all information surrounding an incident, but cannot be kept in a participant's chart, as the report may contain private information regarding another participant or other person. A note by a staff member is filed in the chart pertaining to the participant. 

Recommendation: This regulation should be removed in its entirety.