Compliance Analysis Overview

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COMMONWEALTH of VIRGINIA

ALISON G. LAND, FACHE

COMMISSIONER

DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES Post Office Box 1797 Richmond, Virginia 23218-1797 Telephone (804) 786-3921 Fax (804) 371-6638 www.dbhds.virginia.gov July 9, 2021

After the most recent updates to selected sections were posted for public comment, the final version of the Early Intervention Practice Manual (Guidance Document Part C 9) is available at this link:

HTTPS://WWW.ITCVA.ONLINE/ITCVA-RESOURCE-LIBRARY

If you have any questions about the current Practice Manual Contact:

Catherine Hancock, MS, RN, LNP Early Intervention Program Manager VA Dept. of Behavioral Health & Developmental Services PO Box 1797 1220 Bank St.

Richmond, VA 23218-1797 Office: 804-371-6592 Fax: 804-371-7959

Page 1 of 1

COMMONWEALTH of VIRGINIA

ALISON G. LAND, FACHE

COMMISSIONER

DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES Post Office Box 1797 Richmond, Virginia 23218-1797 Telephone (804) 786-3921 Fax (804) 371-6638 www.dbhds.virginia.gov July 9, 2021

After recent updates posted for public comment, the final Early Intervention Practice Manual (Guidance Document Part C 9) is available at this link:

HTTPS://WWW.ITCVA.ONLINE/ITCVA-RESOURCE-LIBRARY

For questions about the current Practice Manual, contact:

Catherine Hancock, MS, RN, LNP Early Intervention Program Manager VA Dept. of Behavioral Health & Developmental Services PO Box 1797 1220 Bank St.

Richmond, VA 23218-1797 Office: 804-371-6592 Fax: 804-371-7959

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 1

Virginia Department of Behavioral Health and Developmental Services

Funding Guidelines

These annual guidelines are developed in collaboration with the IFSP State Council and published in accordance with regulation, Operation of the Individual and Family Support Program [12VAC35-230].

Version Date: 09/12/2024.

Contents

I.

Program Description .............................................................................................. 2

II.

Program Eligibility Requirements ........................................................................... 2 III. Prioritized Funding Categories ............................................................................... 3 IV. Covered and Non-Covered Services and Supports ................................................. 4

V.

Application for Funding .......................................................................................... 7 VI. Application Review Criteria .................................................................................... 7 VII. Funding Award Process .......................................................................................... 8 VIII. Requests for Reconsideration ................................................................................ 8 IX. Post-Funding Review .............................................................................................. 9

X.

Termination of Funding .......................................................................................... 9

If you have questions or need additional assistance, please contact My Life, My Community operators at (844) 603-9248.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 2

Program Description

12VAC35-230-20

Funding through the Virginia Department of Behavioral Health and Developmental Services’ (“department”) Individual and Family Support Program (“IFSP”) assists individuals on a waiting list for a Virginia Medicaid Home and Community-Based Services (HCBS) Developmental Disability Waiver (“DD Waiver Waiting List”) and their families with accessing resources, supports, and services. The program supports the continued residence of individuals with developmental disabilities in their own homes or in the family home of the individual.

Program Eligibility Requirements

12VAC35-230-35

To be eligible, applicants must meet all of the following criteria when funds are requested:

1. Applicants must be on the Virginia DD Waiver Waiting List, and
2. Applicants must be living in their own homes or in a family home.

Applications may be submitted either by the individual who is on the DD Waiver Waiting List or a custodial family member applying on behalf of the individual(s) on the DD Waiver Waiting List. A “custodial family member” is a family member who has primary authority to make all major decisions affecting the individual and with whom the individual primarily resides.1

Individuals on the DD Waiver Waiting List who also receive assistance through other programs like the Commonwealth Coordinated Care Waiver (CCC Plus) or the Early and Periodic Screening Diagnosis and Treatment Program (EPSDT) may apply for funds if the request is for items that are not available through this or a similar program. IFSP encourages all applicants to maximize assistance by accessing other supports and resources where appropriate.

1 As defined in 12VAC35-230-10, Operation of the Individual and Family Support Program.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 3

Prioritized Funding Categories

12VAC35-230-45 The amount each applicant may request is based upon the applicable prioritized funding category for the applicant.

the program shall approve awards up to approximately $2.5 million in direct assistance to individuals on the DD Waiver Waiting List.

Prioritized Funding Categories Priority 1: Total Funds Available: Approximately 50% of funds will be awarded to applicants with Priority 1 status on the DD Waiver Waiting List.

Maximum Per Recipient: $1000 .

Application Period: Open for one month.

Determination Process:

1. Funds will be awarded to applicants with the highest Critical Needs Summary scores (most at risk of institutionalization) as recorded in the Waiver Management System (WaMS) at the time of application submission, until funds are exhausted.
2. After all Priority 1 funds are allocated, any Priority 1 applicants who remain unfunded shall be included in the random selection process for the remaining funds in the group with Priority 2 and 3 applicants.

Remaining funds: Any funds remaining after all Priority 1 applicants are approved shall be added to the Priority 2 and 3 funding allocation.

Priorities 2 and 3 (combined) and any remaining unfunded Priority 1: Total Funds Available: Approximately 50% of funds will be awarded to applicants with Priority 2 and 3 status on the DD Waiver Waiting List.

Maximum Per Recipient: $500.

Application Period: Open for one month.

Determination Process:

1. All Priority 2 and 3 applicants and all remaining unfunded Priority 1 applicants shall be in the same group for random selection.
2. Funds shall be awarded to applicants in a random, unprioritized manner until all available funds are distributed, with the exception that new applicants and applicants who were denied in the previous year’s funding cycle will be prioritized.

The funding application schedule, including application deadlines, are posted on the My Life, My Community website at https://mylifemycommunityvirginia.org.

All applications must be submitted via the department’s WaMS IFSP Funding DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 4

Application Portal located at https://www.dbhds.virginia.gov/ifsponline.

Applications shall be reviewed by the department at the following intervals: Priority 1: Upon close of the application period.

Priorities 2 and 3: After all Priority 1 applications are reviewed and determinations are made. No later than one month from the close of the application period.

Covered and Non-Covered Services and Supports

12VAC35-230-55

The following items and services are eligible for funding as allowable expenditures under the IFSP.

Please note: IFSP funds are one-time funds and are not guaranteed to be awarded in future years.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 5

Safe Living

• Backup generator
• Furniture, including beds, sofa, chairs, tables, lamps, and dressers
• Adaptive furniture
• Mattresses and bedding
• Handrails and grab bars
• Home modifications to improve accessibility, including door widening, additional flooring, kitchen or bathroom remodels, and driveway and window installation
• Appliances
• Heating, cooling, and plumbing systems conversion, installation, and repairs
• General home repairs
• Location devices and GPS trackers, including Project Lifesaver and AngelSense, personal alarms, locator services, and associated trainings
• Respite
• Fencing
• Home security systems, including home alarms and cameras
• Wheelchair ramp and other ramps
• Stairlifts
• Legal fees, including fees to establish guardianship, power of attorney, microboards, trusts, etc.

Community Integration

• Companion services, peer support, and mentoring
• Childcare and afterschool care
• Community activities/recreation
• Conferences, family education, and trainings
• Day support programs
• Self-advocate education or training
• Summer camp
• Supported employment
• Therapeutic activities and copays
• Transportation services including Uber, Lyft, cabs, buses, etc.
• Sports activities and lessons, including tournaments
• Recreational and entertainment activities that support community integration
• Recreational activities, including art classes, music lessons, dance lessons, gym memberships, etc.
• Recreational equipment, including swings and playset equipment
• In-state vacations
• Passes for recreational activities
• Tuition
• Modifications to a vehicle, including wheelchair lifts
• Reimbursement for transportation costs including gas, tolls, etc.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 6

Improved Health Outcomes

• Attendant care
• Behavior therapy/applied behavioral analysis
• Communication and assistive technology, including computers, tablets, laptops, iPads, apps, mobile phones, mobile phone services, warranties and repairs, internet services, speech applications, and speech products
• Telecommunication services that enhance community access and involvement, including SIM cards, internet, mobile phone service, and applications that link individuals to community activities
• Assistive technology repair
• Dental care, procedures, and equipment
• Hearing care, procedures, and equipment
• Medical care copays
• Medication
• Equipment, including bikes, wheelchairs, strollers, car seats, and highchairs
• Sensory items, including toys

• Nutritional supports, including nutritional drinks like Boost, Ensure, formula, adult formula for feeding tubes, etc.
• Therapies, including occupational therapy, physical therapy, speech therapy, massage therapy, and chiropractic therapy
• Personal hygiene items, including incontinence supplies, skin ointments, wipes, specialized toothbrushes, and costs associated with professional grooming services such as haircuts, manicures, and pedicures
• Therapeutic horseback riding/hippotherapy
• Vision care, procedures, and equipment
• Durable medical equipment, including clothing and compression garments and apparel that simplifies self-dressing and offers solutions to meet a multitude of physical challenges. Eligible clothing items include the following:
• Bibs and clothing protectors
• Soft clothing for sensory sensitivity
• Clothing with velcro, snaps, or zipping closures

• Orthopedic shoes IFSP Funds may NOT cover the following costs:

• Clothing not related to the applicant’s disability2;
• Food (not related to special dietary needs associated with the disability or as part of a recreational experience);
• Installment payments for automobiles and auto insurance; and
• Any services or items not listed in these Guidelines or if covered by another entity.

2 This does not exclude accessible clothing items (e.g., adaptive clothing or footwear, weighted vests). These items are covered under the Improved Health Outcomes section of the list.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 7

Application for Funding

12VAC35-230-65

The application can be found on the WaMS IFSP Funding Application Portal located at https://www.dbhds.virginia.gov/ifsponline.

IFSP funds may only be used to cover expenses incurred after the applicant receives the award approval notice.

All program funds will be issued by debit card. Applicants are expected to register the card immediately upon receipt. Failure to register the card may affect the applicant’s eligibility for future funds.

By applying, the individual or custodial family member agrees to:

1. Maintain all receipts documenting items or services purchased with IFSP funds for three calendar years from the date of purchase and, upon request, provide the receipts to the department for auditing3;
2. Acknowledge that failure to comply with the program’s policies may result in recovery of awarded funds and denial of future funding requests.

Application Review Criteria

Upon receipt of a completed application and prior to issuance of funding, the department shall:

1. Verify that the individual is on the waiting list for a Medicaid Home and Community-Based Services (HCBS) DD Waiver;
2. Confirm that the requested items or services are eligible for funding; and
3. If applicable, confirm that the applicant complied with program requirements in previous years. Failure to provide all the requested application information shall result in an application denial.

3 IFSP stopped requiring receipts in 2020. However, applicants are still expected to maintain receipts documenting expenditures for eligible items and providing them as requested as part of a program audit.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 8

Funding Award Process

12VAC35-230-85

The department shall provide a written notice to the individual or custodial family member who submitted the application indicating whether the application was approved or denied.

Approvals Applications shall be approved according to criteria outlined in Sections I through VI of these guidelines.

Denials Applications may be denied if the department determines that:

• The applicant does not meet the eligibility criteria.
• The requesting individual or custodial family member did not comply with IFSP policies or regulations for previous funding awards. This includes failure in prior years to register debit cards for awards or failure to provide receipts for funds previously received, when requested for review.
• After reviewing all applications, and following approval criteria outlined in the Prioritized Funding Categories Section III, the IFSP funding annual appropriation is expended.

An applicant in Priority 2 or Priority 3 (or remaining unfunded Priority 1) who received IFSP funding the year before may not receive funding again until all other eligible applicants in those priority categories have been awarded funding.

Requests for Reconsideration 12VAC35-230-90 For applications denied for the reasons listed in Section VII, the department shall provide written notice via email stating the reason(s) for denial, and information on how to appeal the decision.

Requests for reconsideration must be submitted in writing using the directions provided in the written denial notice. Reconsiderations must be submitted no later than 30 days after receiving the denial notice. A determination shall be made within 30 days of receipt of the request and provided to the responsible party in writing. This decision will be final.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 9

Review of Requests for Reconsideration Process: The department shall conduct a thorough review of (i) each application received for reconsideration and (ii) the determination process to identify potential errors that may have occurred. If an error is identified that indicates the applicant should have received a funding award, the request for reconsideration will be approved.

Post-Funding Review 12VAC35-230-100 Department staff may request documentation or verification that funds were used in accordance with the program guidelines to purchase only approved services or items as described in the application and approved by the department. By receiving IFSP funds, recipients agree to provide all information requested by the department for three years following the funding cycle in which the funds were awarded. Failure to provide information when requested may result in recovery of the awarded funds by the department or prohibition from receiving future funds.

Termination of Funding

12VAC35-230-110 120

Funding through the IFSP shall be terminated when the individual is enrolled in a Medicaid HCBS DD Waiver, if the individual is found to be no longer eligible to be on a waiting list for a Medicaid HCBS DD Waiver in accordance with 12VAC30-122-90 and all appeals are exhausted, or if awarded funds are used for purposes not approved by the department in its written notice. Any funds approved but not yet released to the awardee will be forfeited in such circumstances.

If you need answers to questions related to IFSP, please visit the DBHDS My Life, My Community website at https://mylifemycommunityvirginia.org.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 1

Virginia Department of Behavioral Health and Developmental Services

Funding Guidelines

These annual guidelines, developed with the IFSP State Council, are published per regulation, Operation of the Individual and Family Support Program [12VAC35-230].

Version Date: 09/12/2024.

Contents

I.

Program Description .............................................................................................. 2

II.

Program Eligibility Requirements ........................................................................... 2 III. Prioritized Funding Categories ............................................................................... 3 IV. Covered and Non-Covered Services and Supports ................................................. 4

V.

Application for Funding .......................................................................................... 7 VI. Application Review Criteria .................................................................................... 7 VII. Funding Award Process .......................................................................................... 8 VIII. Requests for Reconsideration ................................................................................ 8 IX. Post-Funding Review .............................................................................................. 9

X.

Termination of Funding .......................................................................................... 9

For questions or assistance, contact My Life, My Community operators at (844) 603-9248.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 2

Program Description

12VAC35-230-20

Funding via the department’s IFSP assists individuals on the DD Waiver Waiting List and families in accessing resources, supports, and services, supporting their residence in their own or family homes.

Program Eligibility Requirements

12VAC35-230-35

Applicants must meet all criteria when requesting funds:

1. Applicants must be on the Virginia DD Waiver Waiting List, and
2. Applicants must live in their own or family homes.

Applications can be submitted by the individual on the DD Waiver Waiting List or a custodial family member with primary decision authority and residence.

Individuals on the DD Waiver Waiting List receiving other program assistance (e.g., CCC Plus, EPSDT) may apply for funds for unavailable items. Applicants are encouraged to maximize other supports.

1 As defined in 12VAC35-230-10, Operation of the Individual and Family Support Program.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 3

Prioritized Funding Categories

12VAC35-230-45 The requested amount depends on the applicant’s prioritized funding category.

the program shall approve awards up to approximately $2.5 million in direct assistance to individuals on the DD Waiver Waiting List.

Priority 1: About 50% of funds will be awarded to Priority 1 applicants on the DD Waiver Waiting List.

Maximum Per Recipient: $1000 .

Application period: One month.

Determination Process:

1. Funds go to applicants with highest Critical Needs scores (most at risk of institutionalization) in WaMS at application time, until funds run out.
2. Unfunded Priority 1 applicants will join Priority 2 and 3 applicants in a random selection for remaining funds after Priority 1 allocation.

Remaining funds after Priority 1 applicants are approved will be allocated to Priority 2 and 3.

Priority 2 and 3 (combined) and remaining unfunded Priority 1: About 50% of funds will be awarded to these applicants.

Maximum Per Recipient: $500.

Application Period: Open for one month.

Determination Process:

1. Priority 2, 3, and remaining unfunded Priority 1 applicants will be grouped for random selection.
2. Funds will be randomly awarded until exhausted, prioritizing new and previously denied applicants.

Application schedule and deadlines are posted at https://mylifemycommunityvirginia.org.

All applications must be submitted via the department’s WaMS IFSP Funding DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 4

Application Portal located at https://www.dbhds.virginia.gov/ifsponline.

Applications shall be reviewed by the department: Priority 1: Upon close of the application period.

Priorities 2 and 3: After all Priority 1 applications are reviewed, no later than one month from the close of the application period.

Covered and Non-Covered Services and Supports

12VAC35-230-55

Items and services eligible for funding under the IFSP.

Note: IFSP funds are one-time and not guaranteed in future years.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 5

Safe Living

• Backup generator
• Furniture: beds, sofas, chairs, tables, lamps, dressers
• Adaptive furniture
• Mattresses and bedding
• Handrails and grab bars
• Home modifications for accessibility: door widening, flooring, kitchen/bathroom remodels, driveway, windows
• Appliances
• Heating, cooling, and plumbing systems conversion, installation, and repairs
• General home repairs
• Location devices, GPS trackers (e.g., Project Lifesaver, AngelSense), personal alarms, locator services, and trainings
• Respite
• Fencing
• Home security systems, including home alarms and cameras
• Wheelchair ramp and other ramps
• Stairlifts
• Legal fees, including guardianship, power of attorney, microboards, trusts, etc.

Community Integration

• Companion services, peer support, and mentoring
• Childcare and afterschool care
• Community activities/recreation
• Conferences, family education, and trainings
• Day support programs
• Self-advocate education or training
• Summer camp
• Supported employment
• Therapeutic activities and copays
• Transportation services including Uber, Lyft, cabs, buses, etc.
• Sports activities and lessons, including tournaments
• Recreational and entertainment activities that support community integration
• Recreational activities, including art classes, music lessons, dance lessons, gym memberships, etc.
• Recreational equipment (swings, playsets)
• In-state vacations
• Passes for recreational activities
• Tuition
• Vehicle modifications, including wheelchair lifts
• Reimbursement for transportation costs including gas, tolls, etc.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 6

Improved Health Outcomes

• Attendant care
• Behavior therapy/applied behavioral analysis
• Communication and assistive technology, including computers, tablets, apps, phones, services, warranties, repairs, internet, speech apps, and speech products
• Telecommunication services enhancing community access, including SIM cards, internet, mobile service, and apps linking to community activities
• Assistive technology repair
• Dental care, procedures, and equipment
• Hearing care, procedures, and equipment
• Medical care copays
• Medication
• Equipment, including bikes, wheelchairs, strollers, car seats, and highchairs
• Sensory items, including toys

• Nutritional supports, including drinks like Boost, Ensure, formula, adult formula for feeding tubes
• Therapies, including occupational, physical, speech, massage, and chiropractic therapy
• Personal hygiene items, including incontinence supplies, ointments, wipes, specialized toothbrushes, and grooming costs like haircuts, manicures, pedicures
• Therapeutic horseback riding/hippotherapy
• Vision care, procedures, and equipment
• Durable medical equipment, including clothing, compression garments, and apparel that simplifies dressing and addresses physical challenges. Eligible items include:
• Bibs and clothing protectors
• Soft clothing for sensory sensitivity
• Clothing with velcro, snaps, or zipping closures

• Orthopedic shoes IFSP Funds may NOT cover the following costs:

• Clothing not related to the applicant’s disability2;
• Food not related to special dietary needs or recreational experiences
• Installment payments for automobiles and auto insurance; and
• Services or items not listed in these Guidelines or covered by another entity

This includes accessible clothing items (e.g., adaptive clothing, footwear, weighted vests) under Improved Health Outcomes.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 7

Application for Funding

12VAC35-230-65

Application available on the WaMS IFSP Funding Portal at https://www.dbhds.virginia.gov/ifsponline.

IFSP funds cover expenses after the applicant receives award approval.

Funds are issued via debit card; applicants must register immediately, or future eligibility may be affected.

By applying, the individual or custodial family member agrees to:

1. Maintain receipts for items/services purchased with IFSP funds for three years and provide upon request for audits
2. Failure to comply may result in fund recovery and future funding denial

Application Review Criteria

Before funding issuance, upon receiving a complete application, the department shall:

1. Verify individual is on the Medicaid HCBS DD Waiver waiting list
2. Confirm requested items or services are eligible for funding
3. If applicable, confirm applicant's prior compliance; failure to provide required info results in denial

Since 2020, receipts are not required but must be maintained for audits upon request.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 8

Funding Award Process

12VAC35-230-85

The department will notify the applicant or custodial family of approval or denial in writing.

Approvals Applications shall be approved according to criteria outlined in Sections I through VI of these guidelines.

Denials Applications may be denied if the department determines that:

• Applicant does not meet eligibility criteria
• Requester or family member failed to comply with IFSP policies, including prior registration or receipt submission when requested
• After reviewing all applications, and following approval criteria outlined in the Prioritized Funding Categories Section III, the IFSP funding annual appropriation is expended.

Applicants in Priority 2, 3, or unfunded Priority 1 who received funding last year must wait until all other eligible applicants in those categories are funded.

For denials per Section VII, the department will email reasons and appeal info for reconsideration requests 12VAC35-230-90.

Requests for reconsideration must be submitted in writing using the directions provided in the written denial notice. Reconsiderations must be submitted no later than 30 days after receiving the denial notice. A determination shall be made within 30 days of receipt of the request and provided to the responsible party in writing. This decision will be final.

DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024 9

The department will review reconsideration requests for errors; if found, the request will be approved.

Department staff may request documentation to verify funds were used per guidelines; recipients agree to provide info for 3 years, or funds may be recovered or future funds denied.

Termination of Funding

12VAC35-230-110 120

Funding via IFSP terminates when the individual enrolls in a Medicaid HCBS DD Waiver, is ineligible for the waiting list per 12VAC30-122-90, all appeals are exhausted, or funds are used for unapproved purposes. Unreleased funds will be forfeited.

For IFSP questions, visit https://mylifemycommunityvirginia.org.

DBHDS, ORS-01, March 2020 Page 1 of 2 DBHDS Office of Recovery Services (ORS) Certified Recovery Residences Guidance Document (ORS-01)

Per Code of Virginia § 37.2-431.1. Certified Recovery Residences and corresponding DBHDS regulation, Certified Recovery Residences [12VAC35-260]

BACKGROUND In a May 2017 brief, the National Council for Behavioral Health reported: Recovery housing refers to safe, healthy, and substance-free living environments that support individuals in recovery from addiction. While recovery residences vary widely in structure, all are centered on peer support and a connection to services that promote long-term recovery. Recovery housing benefits individuals in recovery by reinforcing a substance-free lifestyle and providing direct connections to other peers in recovery and recovery services and supports.

Many residents live in recovery housing during and/or after outpatient addiction treatment. Length of stay is self-determined and can last for several months to years.

Residents often share resources, give experiential advice about how to access health care and social services, find employment, budget and manage finances, handle legal problems, and build life skills. Many recovery homes are organized under the leadership of [a] house manager and require residents to participate in a recovery program, such as 12-step and other mutual aid groups.1

While many recovery residences are well-run, a national effort has been growing to bring standards to how recovery residences are operated due to “unscrupulous actors running sober living homes who profit off the misery of their occupants.”2

Broad community feedback called for greater oversight for recovery housing in Virginia to ensure the health, safety, and welfare of individuals staying in recovery residences. Chapter 220 of the 2019 Acts of Assembly (HB2045) (http://lis.virginia.gov/cgi-bin/legp604.exe?191+ful+HB2045ER) added a new section numbered § 37.2-431.1 in the Code of Virginia creating an avenue for the certification of recovery residences in Virginia through regulations adopted by the State Board of Behavioral Health and Developmental Services. This legislation was developed through a stakeholder driven process. The State Board of Behavioral Health and Developmental Services adopted 12 VAC 35-260. Certified Recovery Residences, effective March 7, 2020, to implement this legislation.

The regulation creates a voluntary process for entities that meet the qualifications, policies, and practices established by credentialing entities to be certified by the Department of Behavioral Health and Developmental Services (DBHDS or Department) as certified recovery residences. The two credentialing entities specified in the regulation – the Virginia Association of Recovery Residences and

1 National Council for Behavioral Health, Recovery Housing Issue Brief: Information for State Policymakers, https://www.thenationalcouncil.org/wpcontent/uploads/2017/05/Recovery-Housing-Issue-Brief_May-2017.pdf, citing the U.S.

Department of Health and Human Services (HHS), Office of the Surgeon General (2016), Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. p.5-11. Washington, D.C.: HHS, Retrieved from: https://addiction.surgeongeneral.gov/sites/default/files/ surgeon-generals-report.pdf.

2 Governing Magazine, May 14, 2018. Sober Living Homes and the Regulation They Need. Stratman and Aronberg. Retrieved from: https://www.governing.com/gov-institute/voices/col-regulation-sober-living-homes-recovery-residences-need.html.

Oxford House – are nationally-recognized organizations that follow best practice standards for recovery from substance use disorders. The certification process will be administered by the DBHDS Office of Recovery Services (ORS).

Voluntary certification of recovery residences in accordance with 12 VAC 35-260 and including them on a certification list maintained by DBHDS is intended to be utilized by courts, community services boards, individuals, and families to make it easier to locate recovery housing for individuals needing such housing.

CERTIFICATION LIST MAINTAINED BY THE OFFICE OF RECOVERY SERVICES The Certified Recovery Residences regulations, 12 VAC 35-260, become effective March 7, 2020. At that time, entities may begin to submit applications to DBHDS for verification of compliance with the requirements of the regulation, including verification that the entity is certified or accredited by or holds a charter from a credentialing entity. Should a recovery residence choose to be certified by the Department, it must provide evidence that it meets the qualifications, policies, and practices of, and is certified or accredited or holds a charter from one of the following credentialing entities:

• Virginia Association of Recovery Residences (VARR). https://varronline.org/
• Oxford House. https://www.vaoxfordhouse.org/

Once an application has been received, the DBHDS Office of Recovery Services (ORS) will, using regularly updated lists received from VARR or Oxford House, verify the applicant’s accreditation or certification by, charter from, or membership in a credentialing entity. Applications that are approved for certification as a certified recovery residence will be placed on the certification list maintained by ORS: http://www.dbhds.virginia.gov/office-of-recovery-services

Pursuant to 12 VAC 35-260-40(B), any recovery residence that fails to maintain accreditation or certification by, a charter from, or membership in a credentialing entity shall be removed from the certification list. DBHDS will monitor certified recovery residences’ continued compliance with the requirement to maintain their accreditation, certification, charter, or membership. The two credentialing entities, VARR and Oxford House, will notify ORS within three (3) business days of the date an entity is no longer accredited or certified by, or no longer holds a charter or membership with, them for any reason. This notification will be made by completing the Notification of Non-Compliance for a Certified Recovery Residence form and sending it via email to ORS. ORS will update the certification list on a weekly basis.

Questions regarding recovery residences should be directed to: Alethea Lambert, DBHDS Office of Recovery Services Email: Alethea.lambert@dbhds.virginia.gov Phone: 804.371.0462

DBHDS, ORS-01, March 2020 Page 1 of 2 DBHDS Office of Recovery Services (ORS) Certified Recovery Residences Guidance Document (ORS-01)

Per Code of Virginia § 37.2-431.1. Certified Recovery Residences and corresponding DBHDS regulation, Certified Recovery Residences [12VAC35-260]

BACKGROUND In a May 2017 brief, the National Council for Behavioral Health reported: Recovery housing are safe, substance-free living environments supporting recovery. While varied in structure, all focus on peer support and connecting to services that promote long-term recovery, reinforcing a substance-free lifestyle and linking individuals to peers and recovery supports.

Many residents live in recovery housing during or after outpatient treatment. Length of stay is self-determined, lasting months to years.

Residents share resources, advice on accessing healthcare, social services, employment, budgeting, legal issues, and life skills. Many recovery homes are led by a house manager and require participation in recovery programs like 12-step or mutual aid groups.1

While many recovery residences are well-run, a national effort is growing to establish standards due to “unscrupulous actors running sober living homes who profit off occupants’ misery.”2

Broad community feedback called for greater oversight for recovery housing in Virginia to ensure the health, safety, and welfare of individuals staying in recovery residences. Chapter 220 of the 2019 Acts of Assembly (HB2045) (http://lis.virginia.gov/cgi-bin/legp604.exe?191+ful+HB2045ER) added a new section numbered § 37.2-431.1 in the Code of Virginia creating an avenue for the certification of recovery residences in Virginia through regulations adopted by the State Board of Behavioral Health and Developmental Services. This legislation was developed through a stakeholder driven process. The State Board of Behavioral Health and Developmental Services adopted 12 VAC 35-260. Certified Recovery Residences, effective March 7, 2020, to implement this legislation.

The regulation creates a voluntary process for entities that meet the qualifications, policies, and practices established by credentialing entities to be certified by the Department of Behavioral Health and Developmental Services (DBHDS or Department) as certified recovery residences. The two credentialing entities specified in the regulation – the Virginia Association of Recovery Residences and

1 National Council for Behavioral Health, Recovery Housing Issue Brief: Information for State Policymakers, https://www.thenationalcouncil.org/wpcontent/uploads/2017/05/Recovery-Housing-Issue-Brief_May-2017.pdf, citing the U.S.

Department of Health and Human Services (HHS), Office of the Surgeon General (2016), Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. p.5-11. Washington, D.C.: HHS, Retrieved from: https://addiction.surgeongeneral.gov/sites/default/files/ surgeon-generals-report.pdf.

2 Governing Magazine, May 14, 2018. Sober Living Homes and the Regulation They Need. Stratman and Aronberg. Retrieved from: https://www.governing.com/gov-institute/voices/col-regulation-sober-living-homes-recovery-residences-need.html.

Oxford House – are nationally-recognized organizations that follow best practice standards for recovery from substance use disorders. The certification process will be administered by the DBHDS Office of Recovery Services (ORS).

Voluntary certification per 12 VAC 35-260, including listing by DBHDS, aims to help courts, community services, individuals, and families locate recovery housing.

CERTIFICATION LIST MAINTAINED BY THE OFFICE OF RECOVERY SERVICES The Certified Recovery Residences regulations, 12 VAC 35-260, become effective March 7, 2020. At that time, entities may begin to submit applications to DBHDS for verification of compliance with the requirements of the regulation, including verification that the entity is certified or accredited by or holds a charter from a credentialing entity. Should a recovery residence choose to be certified by the Department, it must provide evidence that it meets the qualifications, policies, and practices of, and is certified or accredited or holds a charter from one of the following credentialing entities:

• Virginia Association of Recovery Residences (VARR). https://varronline.org/
• Oxford House. https://www.vaoxfordhouse.org/

Once an application has been received, the DBHDS Office of Recovery Services (ORS) will, using regularly updated lists received from VARR or Oxford House, verify the applicant’s accreditation or certification by, charter from, or membership in a credentialing entity. Applications that are approved for certification as a certified recovery residence will be placed on the certification list maintained by ORS: http://www.dbhds.virginia.gov/office-of-recovery-services

Pursuant to 12 VAC 35-260-40(B), any recovery residence that fails to maintain accreditation or certification by, a charter from, or membership in a credentialing entity shall be removed from the certification list. DBHDS will monitor certified recovery residences’ continued compliance with the requirement to maintain their accreditation, certification, charter, or membership. The two credentialing entities, VARR and Oxford House, will notify ORS within three (3) business days of the date an entity is no longer accredited or certified by, or no longer holds a charter or membership with, them for any reason. This notification will be made by completing the Notification of Non-Compliance for a Certified Recovery Residence form and sending it via email to ORS. ORS will update the certification list on a weekly basis.

Questions regarding recovery residences should be directed to: Alethea Lambert, DBHDS Office of Recovery Services Email: Alethea.lambert@dbhds.virginia.gov Phone: 804.371.0462

DBHDS Guidance LIC18.High Risk.2020.05.28 Page 1 of 4

COMMONWEALTH of VIRGINIA

ALISON G. LAND, FACHE

COMMISSIONER

DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES Post Office Box 1797 Richmond, Virginia 23218-1797 Telephone (804) 786-3921 Fax (804) 371-6638 www.dbhds.virginia.gov

MEMORANDUM

To:

DBHDS Licensed Providers From: Jae Benz, Director, Office of Licensing Cc:

Angelica Howard, Specialized Investigation Unit Manager Date: March 31, 2020 FINAL May 28, 2020 RE: Individuals with Developmental Disabilities with High Risk Health Conditions

Purpose: The purpose of this memo is to inform providers licensed by the Department of Behavioral Health and Developmental Services (“DBHDS”) that provide services to individuals with developmental disabilities (“DD”) of the importance of adequately supporting individuals with high-risk health conditions. High-risk health conditions include decubitus ulcers (“pressure injuries”), aspiration pneumonia, and falls that result in serious injury. DBHDS is committed to continually improving the health and safety of individuals receiving behavioral health and developmental services from DBHDS licensed providers. Rigorous inquiries into serious incident reports (“SIRs”) can identify opportunities for provider and system improvements that will reduce risks to individuals receiving licensed services. This memo also reminds providers of the available resources offered by the DBHDS Office of Integrated Health (“OIH”).

Overview: Current SIR tracking implemented by the Office of Licensing (“OL”) Incident Management Unit (“IMU”) has revealed that there have been incidents regarding individuals with DD who have decubitus ulcers (“pressure injuries”), aspiration pneumonia, and falls that result in serious injuries. This memo serves as a reminder of the importance for licensed providers to ensure that any individuals with DD, that have these identified health conditions, are appropriately supported based on their assessed identified needs. Providers shall ensure that they only accept individuals into their services who they can support and who meet their service description (12VAC35-105-580). In addition, providers must compile appropriate assessments (12VAC35-105-650); develop specific individual service plans (ISPs) and applicable protocols to address identified needs (12VAC35-105-660 and -665); and reassess individuals as new diagnoses occur or when Level II incidents occur (12VAC35-105-160 D 2 and -675 A).

Providers should look at incidents at both the individual level and from a risk management perspective for all individuals (12VAC35-105-520 A-E). In addition, providers are reminded that

DBHDS Guidance LIC18.High Risk.2020.05.28 Page 2 of 4 when reporting SIRs into the DBHDS Computerized Human Rights Information System (“CHRIS”), they should ensure that the correct diagnosis is selected, versus “unknown,” when applicable. Providers should make any updates in the SIR report as soon as possible and no later than 48 hours from the time of their original submission. This will aid with appropriate data collection.

Potential Areas of Assessment: Below are a few examples of potential questions based on the Rules and Regulations for Licensing Providers by the Department of Behavioral Health and Developmental Services (“Licensing Regulations”) [12VAC35-105]. Providers should consider and assess these examples in an effort to prevent or address decubitus ulcers (“pressure injuries”), aspiration pneumonia, and falls resulting in serious injuries. Please note the following is not a comprehensive list and does not serve as a substitute for obtaining a medical assessment from a licensed professional:

• 12VAC35-105-450. Employee Training and Development:

1. Do you have evidence that staff were trained to support the individual with the identified medical diagnosis based on best practice evidence (e.g. skin integrity training, aspiration pneumonia prevention, fall prevention)?
2. Have you ensured that all staff are trained on the required direct support professional (DSP) orientation training and associated competency checklists completed?

• 1VAC35-105-520. Risk Management:

1. Do you have a risk management plan in place to help minimize the risk for the identified individual and for other individuals that is based on best practice evidence?
2. Do you complete safety and environmental check forms to ensure the environment is safe for the individual in an effort to minimize falls based on best practice evidence?

• 12VAC35-105-580.F. Service Description Requirements:

1. Did you ensure that you only admitted individuals whose needs are consistent with your service description? What steps did you take to ensure that you only admitted individuals whose needs are consistent with your service description?
2. What procedures do you have in place for notifying the support coordinator and guardian that you can no longer provide services safely due to health changes?
3. Is there a procedure in place for emergency removal from the home?

• 12VAC35-105-590 C 3. Provider Staffing Plan:

1. Do you have appropriate staffing levels for supervision of the individuals based on their identified needs and best practice evidence?
2. Do you have staff trained in medication administration available for all shifts?

• 12VAC35-105-600. Nutrition:

1. Did you ensure that the individual received the appropriate nutrition and food consistency needed based on current protocol or physician orders?
2. Was all assistive technology and adaptive food equipment used for eating and drinking: a) per physician orders; and b) per speech therapist/physical therapist/occupational therapist (“SPT/PT/OT”) evaluations; and c) consistently carried out across all settings and addressed within the individual’s ISP?
3. Is there adequate supervision or level of support provided to the individual while eating?
4. Is there evidence that all staff are trained in appropriate use of, and support of, assistive technology and adaptive equipment for the individual for eating and drinking: a) per physician orders; and b) per SPT/PT/OT’s evaluations; and c) consistently carried out across all settings and addressed within the individual’s ISP?

DBHDS Guidance LIC18.High Risk.2020.05.28 Page 3 of 4

1. Is there evidence that all staff across all settings are able to describe symptoms of dysphagia (difficulty swallowing)?
2. Is there evidence that all staff across all settings can accurately identify when a consultation with a dietician or SPT is needed?
3. Is there evidence that all staff can accurately identify the functions and services a primary care physician (PCP)/SPT/PT/OT/nurse can provide to an individual?

• 12VAC35-105-620. Monitoring and Evaluating Service Quality:

1. Do you have a quality improvement plan and processes to help identify where improvements in service delivery may be needed to minimize the risk for these types of injuries and to implement quality improvement initiatives?
2. Do you have a system in place to track repeat incidents, hospitalizations, injuries, illnesses, falls, etc., in order to analyze and recognize patterns or trends among the individuals, which can help identify system process issues, educational or training needs, and identify the need for a referral to PCP/SPT/PT/OT/nurse or other specialized medical assessments and treatments?

• 12VAC35-105-650. Assessment Policy:

1. Do you have adequate assessment procedures documented to include reassessments when the injury or event is discovered?
2. Do your assessments include assessing for falls, pressure injuries, aspiration risk, and other potential individual health and safety risks?
3. Did you seek outside assessments of individuals when needed (SPT/OT/PT/nurse, etc.) to include regular safety and maintenance checks of all durable medical equipment (DME) such as wheelchairs, shower chairs, toileting chairs, rollators, walkers, hospital beds, standers, gait trainers, etc.)?
4. Do you have protocols and procedures in place to ensure that individuals who use wheelchairs have an annual seating assessment (best practice) and as needed?
5. Have you requested onsite training (from the Office of Integrated Health) for mobile rehabilitation evaluation/durable medical equipment evaluation/assistive technology (“MRE/DME/AT”) to help you identify the need for a new DME assessment?

• 12VAC35-105-660. Individualized Services Plan (ISP) and -665. ISP Requirements:

1. Did the ISP have adequate health and safety goals, objectives, and interventions to address identified medical and clinical therapeutic needs as indicated via assessments?
2. Are the ISPs individualized such that staff clearly know how to support the individual with medical, positioning, health, and nutritional needs per best practice evidence?
3. Have you documented discussion of identified risks and potential mitigating strategies with the individual and guardian or authorized representative, as applicable, to ensure informed choice and decision making?
4. Can your staff demonstrate a working knowledge of the ISP supports?
5. Are there separate detailed protocols needed to supplement the ISP (i.e., repositioning protocol, nutritional management protocol, fall prevention protocols, and DME/AT/adaptive equipment protocols)?
6. Do you have evidence that staff were trained on the ISP and specific DME/AT/adaptive equipment protocols by specialists such as an SPT/OT/PT, etc.?
7. If you have a nurse on staff, is the nurse attending ISP meetings for those individuals who had a recent serious incident (aspiration, fall, and pressure injury)?

• 12VAC35-105-680. Progress Notes or Other Documentation:

1. Do progress notes support implementation of the ISP?

DBHDS Guidance LIC18.High Risk.2020.05.28 Page 4 of 4

1. Are there any other needed medical tracking forms or documentation to support the ISP goals (repositioning forms for skin pressure prevention, nutritional monitoring forms to document appropriate nutrition and food consistencies for prevention of aspiration pneumonia, body check forms after falls to monitor for any bruising, etc.), based on best practice evidence?

• 12VAC35-105-720. Health Care Policy:

1. Does your health care policy meet regulation requirements and include how identified medical needs like decubitus ulcers (“pressure injuries”), aspiration pneumonia, and high fall risks will be addressed, especially if you currently support individuals with these identified needs, based on best practice evidence?
2. Do you have a policy to identify those individuals who have a fall risk and to develop and implement a fall prevention and management plan for each individual at risk, based on best practice evidence?
3. Does your policy address when staff immediately contact 911 in the event of an emergency and do you have evidence that all staff have been trained in your policy?

• 12VAC35-105-750. Emergency Medical Information:

1. Does your emergency medical information or form include identifying those individuals who are at high risk for decubitus ulcers (“pressure injuries”), aspiration pneumonia, or falls, based on best practice evidence?

• 12VAC35-105-770. Medication Management:

1. Did you ensure all prescribed medications were administered as prescribed (checking medication administration record sheets (“MARS”) and available medications)?
2. Did your staff ensure any medical orders for treatment were followed (repositioning orders, nutritional consistency orders, and ensuring assistive devices like walkers are available to use and in good working condition)?
3. Are all supplies (for prescribed treatments) available per physician’s (PCP or other physician) orders?

Available Resources: The DBHDS Office of Integrated Health’s (OIH) website has several safety alerts and newsletters regarding skin integrity, aspiration pneumonia, and fall prevention, along with other vital resources. OIH also has the Health Support Network, which currently offers the following programs: Mobile Rehab Engineering, Dental Services, and Community Nursing, which provide educational and technical assistance on health and safety related topics.

Providers are highly encouraged to utilize this resource to keep informed about important health alerts that may affect individuals with DD.

Sincerely,

Jae Benz

Jae Benz Director, Office of Licensing

DBHDS

DBHDS Guidance LIC18.High Risk.2020.05.28 Page 1 of 4

COMMONWEALTH of VIRGINIA

ALISON G. LAND, FACHE

COMMISSIONER

DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES Post Office Box 1797 Richmond, Virginia 23218-1797 Telephone (804) 786-3921 Fax (804) 371-6638 www.dbhds.virginia.gov

MEMORANDUM

To:

DBHDS Licensed Providers From: Jae Benz, Director, Office of Licensing Cc:

Angelica Howard, Specialized Investigation Unit Manager Date: March 31, 2020 FINAL May 28, 2020 RE: Individuals with Developmental Disabilities with High Risk Health Conditions

Purpose: This memo informs DBHDS-licensed providers serving individuals with DD of the importance of supporting those with high-risk health conditions, including pressure injuries, aspiration pneumonia, and serious falls. It emphasizes improving health and safety through SIR inquiries and highlights resources from the DBHDS Office of Integrated Health (“OIH”).

Overview: SIR tracking by OL IMU shows incidents involving DD individuals with pressure injuries, aspiration pneumonia, and serious falls. Providers must support individuals based on assessed needs, accept only supportable individuals, complete assessments (12VAC35-105-650), develop ISPs and protocols (12VAC35-105-660, -665), and reassess with new diagnoses or Level II incidents (12VAC35-105-160, -675).

Providers should review incidents individually and from a risk management perspective (12VAC35-105-520 A-E).

When reporting SIRs into CHRIS, providers must select the correct diagnosis instead of “unknown” when applicable, and update reports within 48 hours to ensure accurate data.

Potential assessment areas based on Licensing Regulations (12VAC35-105) include questions to prevent pressure injuries, pneumonia, and falls. This list is not comprehensive or a substitute for medical assessments.

• 12VAC35-105-450. Employee Training and Development:

1. Do you have evidence staff were trained to support the individual’s medical diagnosis per best practice (e.g., skin integrity, pneumonia, fall prevention)?
2. Have you ensured all staff completed required DSP orientation and competency checklists?

• 1VAC35-105-520. Risk Management:

1. Do you have a risk management plan based on best practice to minimize risks for the individual and others?
2. Do you complete safety/environmental checks to ensure a safe environment and minimize falls per best practice?

• 12VAC35-105-580.F. Service Description Requirements:

1. Did you ensure only individuals with needs matching your service description were admitted? What steps were taken?
2. What procedures notify support coordinator and guardian when services can no longer be safely provided due to health changes?
3. Is there an emergency removal procedure from the home?

• 12VAC35-105-590 C 3. Provider Staffing Plan:

1. Do staffing levels adequately supervise individuals based on needs and best practice?
2. Do all shifts have staff trained in medication administration?

• 12VAC35-105-600. Nutrition:

1. Did the individual receive appropriate nutrition and food consistency per protocol or physician orders?
2. Was assistive technology and adaptive equipment used for eating/drinking: a) per physician orders; b) per SPT/PT/OT evaluations; c) consistently across settings and in ISP?
3. Is adequate supervision/support provided during eating?
4. Is staff trained in appropriate use/support of assistive technology/equipment for eating/drinking: a) per physician orders; b) per SPT/PT/OT; c) across all settings and in ISP?

DBHDS Guidance LIC18.High Risk.2020.05.28 Page 3 of 4

1. Can all staff across settings identify symptoms of dysphagia?
2. Can staff across settings identify when a dietician or SPT consultation is needed?
3. Can staff identify functions/services provided by PCP/SPT/PT/OT/nurse?

• 12VAC35-105-620. Monitoring and Evaluating Service Quality:

1. Do you have a quality improvement plan to identify and address service gaps and minimize injury risks?
2. Do you track incidents, hospitalizations, injuries, illnesses, falls, etc., to analyze patterns and identify system issues, training needs, or referrals?

• 12VAC35-105-650. Assessment Policy:

1. Are assessment procedures documented to include reassessments after injuries or events?
2. Do assessments include falls, pressure injuries, aspiration risk, and other safety risks?
3. Did you seek outside assessments (SPT/OT/PT/nurse) and regular safety checks of DME (wheelchairs, shower chairs, etc.)?
4. Do protocols ensure annual and as-needed wheelchair seating assessments?
5. Have you requested onsite training for MRE/DME/AT to identify DME assessment needs?

• 12VAC35-105-660. ISP and -665. ISP Requirements:

1. Did the ISP include health, safety, and therapeutic goals based on assessments?
2. Are ISPs individualized to guide staff support for medical, positioning, health, and nutritional needs?
3. Have risks and mitigation strategies been documented with the individual and guardian to ensure informed decisions?
4. Can your staff demonstrate a working knowledge of the ISP supports?
5. Are separate detailed protocols needed to supplement the ISP (e.g., repositioning, nutritional management, fall prevention, DME/AT/adaptive equipment)?
6. Is there evidence staff were trained on the ISP and DME/AT/adaptive protocols by specialists like SPT/OT/PT?
7. If you have a nurse, does the nurse attend ISP meetings for individuals with recent serious incidents (aspiration, fall, pressure injury)?

• 12VAC35-105-680. Progress Notes or Other Documentation:

1. Do progress notes support ISP implementation?

DBHDS Guidance LIC18.High Risk.2020.05.28 Page 4 of 4

1. Are additional medical tracking forms or documentation needed to support ISP goals (e.g., repositioning for pressure prevention, nutritional monitoring, post-fall body checks), based on best practices?

• 12VAC35-105-720. Health Care Policy:

1. Does your health care policy meet regulations and address medical needs like pressure injuries, aspiration pneumonia, and high fall risks, especially if supporting individuals with these needs?
2. Do you have a policy to identify fall risks and develop/implement fall prevention and management plans for at-risk individuals?
3. Does your policy specify when staff contact 911 in emergencies and include staff training evidence?

• 12VAC35-105-750. Emergency Medical Information:

1. Does your emergency info/form identify individuals at high risk for pressure injuries, aspiration pneumonia, or falls?

• 12VAC35-105-770. Medication Management:

1. Did you ensure all prescribed medications were administered as prescribed (checking MARs and available meds)?
2. Did staff follow medical treatment orders (repositioning, nutritional, assistive devices like walkers in good condition)?
3. Are all supplies for prescribed treatments available per physician’s orders?

Resources: The OIH website offers safety alerts, newsletters on skin, pneumonia, falls, and programs like Mobile Rehab Engineering, Dental, and Community Nursing for education and assistance.

Providers are encouraged to use this resource to stay informed on health alerts affecting individuals with DD.

Sincerely,

Jae Benz

Jae Benz Director, Office of Licensing

DBHDS

DBHDS, LIC 21, August 2020 1

DBHDS Office of Licensing Guidance for Risk Management

Effective: August 27, 2020

Purpose: This document contains guidance to providers regarding the requirements for risk management adopted to address compliance with the Department of Justice's Settlement Agreement with Virginia within the Rules and Regulations for Licensing Providers by the Department of Behavioral Health and Developmental Services [12VAC35-105] (“Licensing Regulations”).

Regulations addressed: Note all regulatory language is formatted in italics while guidance language is in plain text located within boxes under the label “guidance.” 12VAC35-105-20. Definitions. 12VAC35-105-520. Risk management.

Settlement Agreement indicators addressed: V.C.1.1, V.C.1.4, V.C.1.5, V.C.4.1, V.C.4.3, and V.C.4.4

Guidance:

12VAC35-105-20. Definitions.

The following definitions (pending final approval) are relevant to this guidance document: "Risk management" means an integrated system-wide program to ensure the safety of individuals, employees, visitors, and others through identification, mitigation, early detection, monitoring, evaluation, and control of risks. "Root cause analysis" means a method of problem solving designed to identify the underlying causes of a problem. The focus of a root cause analysis is on systems, processes, and outcomes that require change to reduce the risk of harm "Serious incident" means any event or circumstance that causes or could cause harm to the health, safety, or well-being of an individual. The term "serious incident" includes death and serious injury.

12VAC35-105-520. Risk management.

A. The provider shall designate a person responsible for the risk management function who has completed department approved training, which shall include training related to risk management, understanding of individual risk screening, conducting investigations, root cause analysis, and the use of data to identify risk patterns and trends.

Guidance:

All providers are required to designate a qualified person with responsibility for the risk management function.

DBHDS, LIC 21, August 2020 2

Qualifications for this position shall be obtained through the completion of department approved training in these enumerated areas of risk management responsibility:

1. Individual risk screening;
2. Conducting investigations;
3. Root cause analysis; and
4. The use of data to identify risk patterns and trends.

Note that these are minimum qualifications. Providers may also provide training in additional areas relevant to the risk management function, which may include topics such as emergency preparedness, use of universal precautions to prevent infections, prevention of inadvertent release of protected health information (PHI), and other areas of potential risk to providers.

DBHDS will post information about approved training on its website. Providers that the Office of Licensing determines are non-compliant with risk management requirements for reasons that are related to a lack of knowledge will be required to demonstrate that they complete training offered by the Commonwealth or other training determined by the Commonwealth to be acceptable, as part of their corrective action plan (CAP).

B. The provider shall implement a written plan to identify, monitor, reduce, and minimize harms and risk of harm, including personal injury, infectious disease, property damage or loss, and other sources of potential liability.

Guidance:

Providers must have a written risk management plan focused on identifying, monitoring, reducing, and minimizing harms and risk of harm through a continuous, comprehensive approach. This plan should include identifying year-over-trends and patterns and the use of baseline data to assess the effectiveness of risk management systems.

The written risk management plan should be reviewed and updated at least annually, or any time that the provider identifies a need to review and update the plan based on ongoing quality review and risk management activities, such as during its quarterly reviews of all serious incidents.

As required by 12VAC35-105-620, a provider’s risk management plan may be a standalone risk management plan or it may be integrated into the provider’s overall quality improvement plan.

Risk management plans and overall risk management programs should reflect the size of the organization, the population served, and any unique risks associated with the provider’s business model.

In developing a risk management plan, the provider should consider how the following characteristics affect the provider’s level and types of risks:

• How many individuals does the provider serve?
• What are the needs and characteristics of those served?
• What are typical risks associated with this population?
• What services does the provider offer; what risks are involved with these services?
• What is the location(s) where services are provided?
• What is the provider’s business model?

DBHDS, LIC 21, August 2020 3 The risk assessment process is focused on identifying both existing and potential harms and risks of harm. The harms and risk of harm that a risk management plan must focus on identifying, monitoring, reducing, and minimizing, include at least:

• Personal injury;
• Infection disease;
• Property damage or loss; and
• Any other identified source of potential liability.

C. The provider shall conduct systemic risk assessment reviews at least annually to identify and respond to practices, situations, and policies that could result in the risk of harm to individuals receiving services. The risk assessment review shall address at least the following:

Guidance:

An annual risk assessment review is a necessary component of a provider’s risk management plan.

This review should include consideration of harms and risks identified and lessons learned from the provider’s quarterly reviews of all serious incidents conducted pursuant to 12VAC35-105-160.C., including an analysis of trends, potential systemic issues or causes, indicated remediation, and documentation of steps taken to mitigate the potential for future incidents.

The risks enumerated in the regulation are not an exhaustive list. Other risks that providers should consider include:

• Financial risks including whether the provider has sufficient capital to support the business if revenue decreases or is delayed, per 12VAC-35-105-210; and whether the provider has instituted the appropriate checks and balances over financial transactions;
• Business risks; and
• Workforce related risks.

1. The environment of care;

Guidance:

The “environment of care” means the physical environment where services are provided, such as the building and physical premises. A review of the environment of care should consider the results of the annual safety inspection conducted pursuant to 12VAC35-105-520.E, when applicable, but is broader than a safety inspection.

Examples of environmental considerations include such things as:

• The location where services are provided (e.g. in individual’s own home, at a correctional facility, or at a location under the provider’s control);
• How the area where services are provided is arranged;
• Any special protective features that may be present;
• The location, amount, and condition of safety equipment, including: o Fire extinguishers; o First aid kits;

DBHDS, LIC 21, August 2020 4 o Flash lights; o Emergency egress routes and exit signs; and o Any other safety equipment that is or should be present.

• The condition and temperature regulation of refrigerators that store food or medications;
• Security of medication storage;
• Condition of electrical cords, outlets, and electrical equipment;
• The adequacy, suitability, and condition of lighting; and
• Any other physical features that could present safety risks if not properly arranged, secured, maintained, or otherwise addressed.

Environment of care considerations will be different when services are provided at a location that is not under the direct control of the provider, such as at an individual’s own home. While providers are more limited in their ability to assess some of the factors listed above in these locations, providers should consider any unique risks associated with the provision of services in these locations during its risk assessment review. In such cases the review does not need to consider each location (e.g. each home) individually, but should identify risks that may be common across the different locations or settings.

1. Clinical assessment or reassessment processes;

Guidance:

Examples of assessments include physical exams that are completed prior to admission or any time that there is a change in the individual’s physical or mental condition.

Reassessments include: (i) reviews of incidents in which the individual was involved, and (ii) reviews of the individual’s health risks.

Persons designated as responsible for the risk management function need not be engaged in the clinical assessment or reassessment process, but should review these processes during the risk assessment review process. For example, are assessment processes effectively identifying and mitigating risks unique to each individual?

1. Staff competence and adequacy of staffing;

Guidance:

Examples of factors related to staff competency and adequacy of staffing include whether:

• All employees meet minimum qualifications to perform their duties;
• All employees complete orientation training prior to being assigned to perform direct care work;
• All employees have undergone background checks;
• All employees have completed abuse and neglect training;
• All employees have up to date CPR certification;
• Employees who administer medications have received requisite training;
• Employees have completed additional training applicable to their job functions, such as initial and annual fire safety training;
• Staffing schedules are consistent with the provider’s staffing plan; and DBHDS, LIC 21, August 2020 5
• The staffing plan continues to be adequate to meet the needs of the individuals being served.

Reviews of serious incidents over the prior year may help to inform this consideration.

1. Use of high risk procedures, including seclusion and restraint; and

Guidance:

In addition to seclusion and restraint, examples of high risk procedures may include:

• The administration of high risk medications;
• High risk methods of medication administration;
• Procedures used to transfer individuals who require assistance transferring from one location to another; and
• Any other procedure that may pose a greater than average risk to the health and safety of individuals, staff members, or third parties.

Examples of high risk procedure considerations include the following:

• Whether the use of seclusion and restraint, and other high risk procedures are in compliance with the Regulations to Assure the Rights of Individuals Receiving Services from Providers Licensed, Funded, or Operated by the Department of Behavioral Health and Developmental Services [12VAC35-115] (“Human Rights Regulations”) and the Licensing Regulations and any other applicable laws and regulations that govern their use;
• Identification and review of procedures that are typically conducted by the provider which are potentially high risk;
• Whether staff who are permitted to implement high risk procedures have the requisite training, experience, and qualifications to do so safely and in accordance with regulation;
• Whether all high risk procedures are properly authorized and reviewed per policy, regulation, and law; and
• The findings from any root cause analysis is conducted when a high risk procedure causes or is otherwise associated with a serious injury.

1. A review of serious incidents.

Guidance:

The provider’s systemic risk review shall evaluate serious incidents at least annually. Examples of considerations related to serious incidents include whether:

• All Level I serious incidents were reviewed at least quarterly to identify trends in accordance with 12VAC35-105-160;
• Any patterns or trends that have been identified require additional safeguards or risk mitigation strategies;
• The provider has an updated policy that defines who has the authority and responsibility to act when a serious incident or a pattern of serious incidents indicates that an individual is at risk; and
• Serious incidents and patterns of serious incidents are reviewed and appropriate follow-up is conducted or implemented to address individual or system-level risks.

DBHDS, LIC 21, August 2020 6

D. The systemic risk assessment review process shall incorporate uniform risk triggers and thresholds as defined by the department.

Guidance:

DBHDS will disseminate information about uniform risk triggers and thresholds in separate guidance when they are developed.

E. The provider shall conduct and document that a safety inspection has been performed at least annually of each service location owned, rented, or leased by the provider. Recommendations for safety improvement shall be documented and implemented by the provider.

Guidance:

An annual safety inspection must be completed at each service location. This inspection should evaluate the premises for safety concerns.

Examples of safety concerns include the operability of fire safety equipment, emergency egress routes, any cooking and electrical devices on the premises, and trip hazards or other dangerous items or scenarios.

F. The provider shall document serious injuries to employees, contractors, students, volunteers, and visitors that occur during the provision of a service or on the provider's property. Documentation shall be kept on file for three years. The provider shall evaluate serious injuries at least annually.

Recommendations for improvement shall be documented and implemented by the provider.

Guidance:

Failure to document serious injuries to employees, contractors, students, volunteers, and visitors will result in the issuance of a licensing report citing 12VAC35-105-520.F.

Documented serious injuries to employees, contractors, students, volunteers, and visitors shall be evaluated at least annually. This evaluation shall include identification of recurring serious injuries, trends, any other indication of systemic safety deficiencies, and planned steps to remedy the same.

The evaluation and planned remediation steps should be incorporated into or aligned with the provider’s annual systemic risk assessment review process or both.

• Please note that Level II incidents include “a significant harm or threat to the health or safety of others caused by an individual.” Therefore, if a serious injury was caused by an individual to an employee, contractor, student, volunteer, or visitor during the provision of services or on the provider’s premises the serious injury should also be reported into CHRIS within 24 hours of discovery as a Level II serious incident.

DBHDS, LIC 21, August 2020 1

DBHDS Office of Licensing Guidance for Risk Management

Effective: August 27, 2020

Purpose: This guidance outlines risk management requirements to ensure compliance with the Department of Justice's Settlement Agreement within 12VAC35-105 (“Licensing Regulations”).

Regulations addressed: Italicized regulatory language; guidance in boxes labeled “guidance.” 12VAC35-105-20. Definitions. 12VAC35-105-520. Risk management.

Settlement Agreement indicators: V.C.1.1, V.C.1.4, V.C.1.5, V.C.4.1, V.C.4.3, V.C.4.4

Guidance:

12VAC35-105-20. Definitions.

Definitions (pending final approval): "Risk management" is a system-wide program ensuring safety via risk identification, mitigation, detection, monitoring, evaluation, and control. "Root cause analysis" identifies underlying causes of problems, focusing on systems and processes needing change to reduce harm. "Serious incident" includes events causing or risking harm, including death and serious injury.

12VAC35-105-520. Risk management.

A. The provider shall designate a person responsible for the risk management function who has completed department approved training, which shall include training related to risk management, understanding of individual risk screening, conducting investigations, root cause analysis, and the use of data to identify risk patterns and trends.

Guidance:

All providers must designate a qualified person responsible for risk management.

DBHDS, LIC 21, August 2020 2

Qualifications for this position require completion of department-approved training in risk management areas:

1. Individual risk screening;
2. Conducting investigations;
3. Root cause analysis; and
4. Using data to identify risk patterns and trends.

These are minimum qualifications; providers may offer additional training in areas like emergency preparedness, infection control, PHI protection, and other risks.

DBHDS will post approved training info online. Non-compliant providers must complete acceptable training as part of their CAP.

B. The provider shall implement a written plan to identify, monitor, reduce, and minimize harms, including injury, infectious disease, property damage, and liability.

Guidance:

Providers must have a written, continuous risk management plan to identify, monitor, reduce harms, analyze trends, and use baseline data to assess effectiveness.

The plan must be reviewed and updated annually or as needed based on ongoing reviews, including quarterly serious incident reviews.

Per 12VAC35-105-620, the risk management plan can be standalone or part of the overall quality improvement plan.

Risk management plans should reflect organization size, population served, and unique risks.

In developing the plan, providers should consider how these characteristics affect risk levels and types:

• Number of individuals served?
• Needs and characteristics of those served?
• Typical risks for this population?
• Services offered and associated risks?
• Service location(s)?
• Provider’s business model?

DBHDS, LIC 21, August 2020 3 The risk assessment process is focused on identifying both existing and potential harms and risks of harm. The harms and risk of harm that a risk management plan must focus on identifying, monitoring, reducing, and minimizing, include at least:

• Personal injury;
• Infection disease;
• Property damage or loss; and
• Any other identified source of potential liability.

C. Providers shall conduct annual systemic risk assessments to identify practices, situations, or policies that could cause harm, addressing at least:

Guidance:

An annual risk assessment is essential to the risk management plan.

This review should consider harms, risks, lessons from quarterly serious incident reviews 12VAC35-105-160, including trend analysis, systemic issues, remediation, and mitigation steps.

The regulation's risks are not exhaustive; providers should also consider:

• Financial risks, including provider's capital sufficiency during revenue delays and checks over financial transactions, per 12VAC-35-105-210;
• Business risks; and
• Workforce related risks.

1. The environment of care;

Guidance:

“Environment of care” is the physical setting, including buildings. Review should consider annual safety inspections 12VAC35-105-520.E, but is broader than safety checks.

Environmental considerations include:

• Location where services are provided (e.g., in individual's home, correctional facility, or under provider’s control);
• Arrangement of service area;
• Presence of protective features;
• Location, quantity, and condition of safety equipment (fire extinguishers, first aid kits);

DBHDS, LIC 21, August 2020 4 o Flash lights; o Emergency egress routes and exit signs; and o Any other safety equipment that is or should be present.

• Refrigerator condition and temperature regulation;
• Security of medication storage;
• Electrical cords, outlets, and equipment condition;
• Lighting adequacy, suitability, and condition;
• Other physical features posing safety risks if unaddressed;

For services in locations outside provider control, like homes, consider unique risks during assessments; review should identify common risks across settings, not each individually.

1. Clinical assessment/reassessment processes;

Guidance:

Examples include pre-admission physicals or assessments after condition changes.

Reassessments include: (i) incident reviews involving the individual, and (ii) reviews of the individual’s health risks.

Risk management personnel need not conduct assessments but should review these processes to ensure risks are identified and mitigated for each individual.

1. Staff competence and adequacy of staffing;

Guidance:

Staff competency and staffing adequacy include whether:

• Employees meet minimum qualifications;
• Employees complete orientation before direct care duties;
• Employees undergo background checks;
• Employees complete abuse and neglect training;
• Employees maintain current CPR certification;
• Medication administrators receive requisite training;
• Employees complete additional job-specific training, including fire safety;
• Staffing schedules align with the staffing plan; DBHDS, LIC 21, August 2020 5
• Staffing plan remains adequate for individuals' needs.

Review of serious incidents from the past year may inform this consideration.

1. Use of high-risk procedures (seclusion, restraint);

Guidance:

High risk procedures, besides seclusion and restraint, may include:

• High-risk medication administration;
• High risk methods of medication administration;
• Procedures for assisting individuals in transferring between locations; and
• Other procedures posing above-average risk to individuals, staff, or third parties.

High risk procedure considerations include:

• Compliance of seclusion, restraint, and high-risk procedures with Human Rights Regulations, Licensing Regulations, and applicable laws [12VAC35-115].
• Identification and review of provider-conducted, potentially high-risk procedures;
• Whether staff authorized for high-risk procedures have necessary training, experience, and qualifications;
• Whether high-risk procedures are properly authorized and reviewed per policy, regulation, and law; and
• Findings from root cause analysis when high-risk procedures cause or relate to serious injury.

1. A review of serious incidents.

Guidance:

The provider shall evaluate serious incidents annually. Considerations include whether:

• All Level I incidents reviewed quarterly to identify trends per 12VAC35-105-160;
• Identified patterns or trends require additional safeguards or risk mitigation;
• Provider's updated policy defines authority and responsibility to act when serious incidents or patterns indicate risk;
• Serious incidents and patterns are reviewed, with follow-up to address risks;

DBHDS, LIC 21, August 2020 6

The systemic risk review shall incorporate uniform risk triggers and thresholds as defined by the department.

Guidance:

DBHDS will issue guidance on uniform risk triggers and thresholds when developed.

The provider shall annually conduct and document safety inspections of each location. Safety improvement recommendations shall be documented and implemented.

Guidance:

An annual safety inspection must evaluate each location for safety concerns.

Safety concerns include fire safety equipment, emergency egress, cooking and electrical devices, trip hazards, and other dangers.

The provider shall document serious injuries to employees, contractors, students, volunteers, and visitors occurring during services or on property, kept for three years, and evaluated annually.

Recommendations shall be documented and implemented.

Guidance:

Failure to document serious injuries will result in a licensing report citing 12VAC35-105-520.

Documented serious injuries shall be evaluated annually, including recurring injuries, trends, safety deficiencies, and remediation steps.

Evaluation and remediation steps should align with or be part of the annual systemic risk review.

• Level II incidents involve significant harm or threat caused by an individual; serious injuries to staff, contractors, students, volunteers, or visitors must be reported to CHRIS within 24 hours.

DBHDS OHR 02, 2024.09.16, Page 1 of 4

DBHDS Office of Human Rights (OHR) Uses of Video and Audio Monitoring in Provider Service Settings

Effective 09/16/2024

Purpose Individuals receiving services licensed, funded, or operated by the Department of Behavioral Health and Developmental Services (“department” or “DBHDS”) have the right to reasonable privacy [12VAC35-115-50 C 3 a] and confidentiality [12VAC35-115-80]. The information provided in this guidance is regarding the use of monitoring devices as necessary for safety and operational purposes in a provider service setting relative to provider policies and the Regulations to Assure the Rights of Individuals Receiving Services from Providers Licensed, Funded, or Operated by the Department of Behavioral Health and Developmental Services (“Human Rights Regulations,”

12VAC35-115).

Defined Terms (See 12VAC35-115-30.) “Individual” means a person who is receiving services. The term includes the terms “consumer,” “patient,” “resident,” “recipient,” and “client.”

“Local human rights committee” or “LHRC” means a group of at least five volunteers appointed by the State Human Rights Committee. (The LHRC shall review any restriction on the rights of any individual imposed pursuant to 12VAC35-115-50. Dignity or 12VAC35-115-100. Restrictions on Freedoms of Everyday Life, that lasts longer than seven days or is imposed three or more times in a 30-day period and shall review behavioral treatment plans with restrictions, restraint or timeout pursuant to 12VAC35-115-105. Behavioral Treatment Plans for providers within the LHRC’s jurisdiction.)

“Monitoring device” is not a defined term in the Human Rights Regulations; however, when used in this document, it refers to any equipment used by a provider to capture, record, or transmit an image or sound, including audio or video.

“Provider” means any person, entity, or organization offering services that is licensed, or funded, or operated by the department.

DBHDS OHR 02, 2024.09.16, Page 2 of 4 “Restriction” means anything that limits or prevents an individual from freely exercising his rights.1

“Services” means care, treatment, training, habilitation, interventions, or other supports, including medical care, delivered by a provider licensed, operated, or funded by the department.

Provider Policies

Any providers that determine the need to utilize monitoring devices in a service setting must have policies and procedures that make clear for individuals, families, and staff the purpose for the use of the monitoring and how the provider will ensure individuals’ confidentiality, safety, and privacy.

Providers must make certain that processes established for monitoring will not be used to diminish or substitute for staff responsibilities specific to supervision and support of individuals receiving services.

Provider policies and procedures must:  Specify whether the monitoring device is equipped with the capacity for audio or video or both;  Identify the location of the monitoring device(s);  Specify who is responsible for and who will have access to the live video, audio, or recordings;  Explain the process used for review of audio or video and whether it will be reviewed in real-time or at established intervals;  Specify whether access and review of live video or audio or recordings is limited to on-site viewing or is available for access remotely (off-site). If remote access is provided, indicate from where an authorized user may obtain access (i.e., provider staff may view only onsite from an administrative office, or from the staff’s home office, from an agency-issued cell phone, etc.);  Detail quality controls in place to ensure against unauthorized viewing, sharing, or tampering with the monitoring device(s) or recordings. This should include a process to remove access to view live or recorded audio or video when a previously authorized person no longer requires access for their duties, or the previously authorized person is no longer associated with the provider;  Indicate how long video or audio recordings will be stored, where they will be stored, and when they will be erased;  Describe how all staff, individuals, parents, guardians, and authorized representatives, if applicable, will be notified of the monitoring policy and procedures (e.g., upon hire, prior to admission) and outline procedures for obtaining signed written acknowledgments attesting to their understanding of the policy and procedures;

1 Note: The full definition currently in regulation includes “privilege,” but that definition is expected to be edited in a regulatory action to make clear the distinction between a restriction and the “privilege” process used by DBHDS for individuals receiving services within state facilities who have a forensic status.

DBHDS OHR 02, 2024.09.16, Page 3 of 4  Make clear that all required oversight and protection agencies will have access to all recordings upon request, including the DBHDS Offices of Human Rights and Licensing, DSS Adult and Child Protective Services (APS and CPS), and law enforcement.  Acknowledge that recordings that identify an individual or otherwise include protected health information (PHI) such as full-face photos, photos of unique identifying marks, or discussion of services are subject to HIPAA. If a recording identifies an individual or contains PHI, it must be stored, used, and disclosed only in accordance with state and federal law.

Any new policy or policy change that impacts the rights of individuals receiving services requires review by the Office of Human Rights (12VAC35-115-260 A 9) prior to implementation.

Local Human Rights Committee Review When positioned in common areas and the protections referenced above have been addressed in a provider’s policy and procedures, the use of monitoring devices does not require review by a Local Human Rights Committee (LHRC).

When the use of a monitoring device is being considered for placement in a non-common area such as inside a bathroom or bedroom, or the monitoring device is being considered for use as an individualized support, the provider must submit all applicable proposed policies, procedures, or individualized services plans (ISPs) to the Human Rights advocate for review, prior to implementation (12VAC35-115-260). At a minimum, the ISP shall include the type of monitoring (audio or video or both); the reason for the monitoring; the specific location of the monitoring device; and detailed procedures for the use of the device. For example, “staff will turn off the monitor when the individual is changing their clothes,” or “the monitor will only be used during sleeping hours.” If after consultation with the advocate, the proposed use of the monitoring device is determined to be a restriction for the individual, the provider will follow the appropriate process outlined in 12VAC35-115-50, 12VAC35-115-100, or 12VAC35-115-105 in order to implement the restriction. This may include review by an LHRC.

All provider requests for review by an LHRC must be submitted using a standard form and process. A recorded overview of the LHRC review forms and process are available on the OHR webpage, under the “Resources for Providers” tab linked here. The assigned advocate will review with the provider regulatory requirements associated with the type of review being requested and provide information about upcoming scheduled LHRC meetings. The LHRC Meeting Schedule and due dates for submitting agenda items are located on the OHR webpage, under the “LHRC and SHRC” tab linked here.

Assurance of Rights (See 12VAC35-115-40.) Residential and inpatient programs should have signage posted notifying anyone entering the location(s) that monitoring is occurring.

DBHDS OHR 02, 2024.09.16, Page 4 of 4 Providers are responsible for ensuring individuals are aware of their rights and the procedure for filing and resolving a complaint for violation of their rights. Information provided to individuals must be in the manner, format, and language most frequently understood by each individual, and include at a minimum, the name and current contact information of each individual’s assigned regional advocate and a description of the human rights advocate's role.

Any individual or authorized representative, if applicable, who believes an individual’s rights were violated, can make a complaint directly with the provider or through the human rights advocate: Office of Human Rights Contact List.

DBHDS OHR 02, 2024.09.16, Page 1 of 4

DBHDS Office of Human Rights (OHR) Uses of Video and Audio Monitoring in Provider Service Settings

Effective 09/16/2024

Individuals receiving services licensed, funded, or operated by DBHDS have rights to privacy [12VAC35-115-50 C 3 a] and confidentiality [12VAC35-115-80]. This guidance addresses monitoring device use for safety and operational purposes under provider policies and the Human Rights Regulations.

12VAC35-115).

Defined Terms (See 12VAC35-115-30.) “Individual” means a person receiving services, including “consumer,” “patient,” “resident,” “recipient,” and “client.”

“LHRC” is a group of at least five volunteers appointed by the State Human Rights Committee that reviews restrictions on rights lasting over 7 days, imposed 3+ times in 30 days, and behavioral treatment plans with restrictions, restraint, or timeout.

“Monitoring device” is not defined in regulations but refers to equipment used by providers to capture, record, or transmit image or sound, including audio or video.

“Provider” means any person, entity, or organization offering services licensed, funded, or operated by the department.

DBHDS OHR 02, 2024.09.16, Page 2 of 4 “Restriction” means anything limiting or preventing an individual’s rights.

“Services” means care, treatment, training, habilitation, interventions, or supports, including medical care, provided by a licensed, operated, or funded provider.

Provider Policies

Providers using monitoring devices must have policies clarifying their purpose and how they will ensure individuals’ confidentiality, safety, and privacy for individuals, families, and staff.

Providers must ensure monitoring processes do not replace or diminish staff supervision and support responsibilities.

Provider policies must specify device capabilities (audio/video), location, responsible parties, review process, remote access, quality controls, storage duration, and notification procedures with signed acknowledgments.

Note: The regulation’s full definition includes “privilege,” but it is expected to be clarified to distinguish restrictions from privileges for forensic individuals in state facilities.

All oversight agencies will have access to recordings upon request. Recordings with PHI or identifying info are subject to HIPAA and must be stored and used per law.

Any new or changed policy affecting individuals’ rights must be reviewed by the Office of Human Rights before implementation.

In common areas, if policies address protections, monitoring device use does not require LHRC review.

For non-common areas or individualized supports, providers must submit policies and ISPs detailing monitoring type, purpose, location, and procedures for review before use. Restrictions require following specific processes, possibly LHRC review.

Providers must submit LHRC review requests via standard forms. Advocates review requirements and inform providers of LHRC schedules, available on the OHR webpage.

Programs must post signage informing entrants that monitoring occurs.

DBHDS OHR 02, 2024.09.16, Page 4 of 4 Providers are responsible for ensuring individuals are aware of their rights and the procedure for filing and resolving a complaint for violation of their rights. Information provided to individuals must be in the manner, format, and language most frequently understood by each individual, and include at a minimum, the name and current contact information of each individual’s assigned regional advocate and a description of the human rights advocate's role.

Anyone believing rights were violated can file complaints with the provider or through the Office of Human Rights Contact List.

Revised.DBHDS, LIC16, November 2020 1

DBHDS Office of Licensing Guidance for a Quality Improvement Program

Effective: November 28, 2020

Purpose: This document contains guidance to providers regarding the requirements for quality improvement adopted to address compliance with the US Department of Justice's Settlement Agreement with Virginia within the Rules and Regulations for Licensing Providers by the Department of Behavioral Health and Developmental Services [12VAC35-105] (“Licensing Regulations”).

Regulations addressed: Note all regulatory language is formatted in italics while guidance language is in plain text located within boxes under the label “guidance.” 12VAC35-105-620. Monitoring and Evaluating Service Quality.

12VAC35-105-620. Monitoring and evaluating service quality.

A. The provider shall develop and implement written policies and procedures for a quality improvement program sufficient to identify, monitor, and evaluate clinical and service quality and effectiveness on a systematic and ongoing basis.

Guidance:

A quality improvement (QI) program is the structure used to implement quality improvement efforts. The structure of the program shall be documented in the provider’s policies.

[Note: If you are a provider of group home, sponsored residential, supervised living residential, or day support services offered in the Developmental Disability (DD) waivers, and your agency is currently engaged in efforts to come into compliance with the Home and Community Based Services (HCBS) settings requirements (42 CFR § 441.301), consider including those efforts into your QI program.]

B. The quality improvement program shall utilize standard quality improvement tools, including root cause analysis, and shall include a quality improvement plan.

Guidance:

12VAC35-105-20 defines a quality improvement plan as “a detailed work plan developed by a provider that defines steps the provider will take to review the quality of services it provides and to manage initiatives to improve quality. A quality improvement plan consists of systematic and continuous actions that lead to measurable improvement in the services, supports, and health status of the individuals receiving services.”

Revised.DBHDS, LIC16, November 2020 2

C. The quality improvement plan shall:

1. Be reviewed and updated at least annually;

Guidance:

There is no specific template required for creating a quality improvement plan; however, staff responsible for implementation of the quality improvement plan must review and update the plan at least annually (every 365 days).

o If needed, the provider must update the plan more frequently based on defined goals and the occurrence of relevant events, such as the issuance of a licensing report. Providers are not required to update their quality improvement plan each time a licensing report is issued. However, anytime a provider is issued a licensing report, the provider should review their quality improvement plan to determine whether their current plan is sufficient to address the concerns identified in the licensing report and to monitor compliance with the provider’s pledged CAP. If the current quality improvement plan is not sufficient, then the provider will need to update the plan accordingly. o Providers should have a clear written plan for how they will evaluate their current quality improvement plan to determine if it is sufficient to address the concerns identified in the licensing report and to monitor their pledged CAPs.

The written plan shall include the person responsible for the reviews as well as how each review will be documented and stored, so that compliance may be determined by the licensing specialist during reviews. o As providers experience changes in systems or programs, the quality improvement plan should be reviewed to ensure that it continues to be relevant. o Annual and other reviews of the quality improvement plan should include evaluation of the components of the program, efficacy of the plan, and whether any updates are needed to accomplish the plan’s goals. o The quality improvement plan should be dated and signed to indicate when it is implemented and when any updates occur.

1. Define measurable goals and objectives;

Guidance:

Identifying goals and objectives may start with consideration of the individuals served and the types of services provided.

A provider’s quality improvement plan should include goals and objectives that are operationally defined and measurable, and a schedule for monitoring progress towards achieving the planned goals and objectives. Establishing a measurable objective may start with the question, “How will I know that there has been improvement or that the objective was achieved?” For example, if the objective of a residential provider is to reduce the number of injuries sustained, this objective could be stated as, “Reduce the rate of serious injuries by X% by June 1, 2021.”

This regulation does not require the provider to set a specific number of goals and objectives. Providers may wish to select only a few goals and then revise or expand the Revised.DBHDS, LIC16, November 2020 3

list as evaluations indicate. Providers collecting data already may consider using the data to identify areas for improvement. o For example, if data from fire drills indicates that it is taking longer to evacuate individuals than expected, the provider may set an objective to reduce the time to evacuate individuals from the facility from X minutes to Y minutes by [specific date]. Other goals and objectives could be tied to maintaining a well-trained workforce (i.e., objective of low turnover) or compliance with the HCBS settings requirements, if applicable. o Other examples of data driven objectives could include:
Increase the percentage of individuals with employment outcomes; or
Increase the percentage of individuals who participate in advocacy groups.

When establishing measurable goals and objectives, a provider may consider the following: o Is it is clear what is being measured and why? Is there a statement that defines what is to be measured? o What collection methods and sources of data are available? o What is the baseline data, if available? o What is the frequency of measurement? (e.g., monthly, quarterly, semiannually) o How will the provider know if goals and objectives were met? o What is the timeframe for achieving the goal or objective? o Who will be accountable for collecting data, analyzing data, and ensuring that relevant goals or objectives are met?

1. Include and report on statewide performance measures, if applicable, as required by

DBHDS;

Guidance:

Statewide performance measures currently in effect were developed by the DBHDS Office of Developmental Services and apply only to DBHDs licensed providers of developmental services.

If additional statewide performance measures are developed, DBHDS will provide information regarding reporting and expectations to licensed providers.

1. Monitor implementation and effectiveness of approved corrective action plans pursuant to 12VAC35-105-170; and

Guidance:

A provider’s quality improvement plan should include the process the provider will use to monitor the implementation of CAPs, including criteria for when a CAP will no longer be subject to monitoring. The provider should identify any systematic actions that may be taken to address deficiencies identified by citations or CAPs and incorporate these into their quality improvement plan.

This may include establishing measurable objectives that are related to the corrective actions and evaluating the degree to which these objectives have been achieved.

Revised.DBHDS, LIC16, November 2020 4

o For example, if a provider was cited for errors in medication administration, they may develop a CAP to reduce errors, and then establish a specific objective for X% reduction in number of medication errors in the next quarter. This could be measured through a chart review and reported as part of the quality improvement program.

1. Include ongoing monitoring and evaluation of progress toward meeting established goals and objectives.

Guidance:

A quality improvement program must include a process defining when and how the provider will review progress toward the goals and objectives of the program.

This may occur through establishing a quality council that regularly meets to review progress or through an established meeting structure.

This process should include an evaluation as to whether or not the goals and objectives of the quality improvement plan were met, whether the goals and objectives should be revised, and if a new quality improvement initiative should be considered to better meet the goals and objectives.

D. The provider’s policies and procedures shall include the criteria the provider will use to:

1. Establish measurable goals and objectives;

1. Update the provider’s quality improvement plan; and

1. Submit revised corrective action plans to the department for approval or continue implementing the corrective action plan and put into place additional measures to prevent the recurrence of the cited violation and address identified systemic deficiencies when reviews determine that a corrective action was fully implemented but did not prevent the recurrence of the cited regulatory violation or correct a systemic deficiency pursuant to 12VAC35-105-170.

Guidance:

Provider policies and procedures must include the processes by which the provider will develop, implement, and update its quality improvement plan, and thereby demonstrate an ongoing, constant process.

The provider’s policies and procedures must address the steps that the provider will take when the provider determines that an approved CAP was fully implemented, but did not resolve the underlying issue (e.g., even though the CAP was fully implemented, the regulatory violation that the CAP was adopted to prevent still recurred, or an underlying systemic deficiency was not resolved). In this scenario, the provider may: o Continue to implement the CAP, but adopt additional corrective measures and incorporate those additional measures into the quality improvement plan, or o If the provider wishes to revise the CAP, the provider must submit a revised CAP to the department for approval.

For additional information related to 12VAC35-105-620.D.2. and 12VAC35-105-170 please Revised.DBHDS, LIC16, November 2020 5

see the DBHDS Office of Licensing’s Guidance on Corrective Action Plans (CAPs).

E. Input from individuals receiving services and their authorized representatives, if applicable, about services used and satisfaction level of participation in the direction of service planning shall be part of the provider’s quality improvement plan. The provider shall implement improvements, when indicated.

Guidance:

Provider quality improvement programs must incorporate input from individuals and their authorized representatives, when applicable, including input related to the level of satisfaction with the level of participation for individuals related to service planning; and, when improvements are indicated based on this input, such improvements shall be implemented.

Revised.DBHDS, LIC16, November 2020 1

DBHDS Office of Licensing Guidance for a Quality Improvement Program

Effective: November 28, 2020

Purpose: This guidance outlines provider requirements for quality improvement to ensure compliance with the US DOJ Settlement Agreement with Virginia under 12VAC35-105 (“Licensing Regulations”).

Regulations addressed: Italicized regulatory language; guidance in boxes labeled “guidance.” 12VAC35-105-620. Monitoring and Evaluating Service Quality.

12VAC35-105-620. Monitoring and evaluating service quality.

A. The provider shall develop and implement written policies and procedures for a QI program to identify, monitor, and evaluate clinical and service quality systematically and continuously.

Guidance:

A QI program is the structure for implementing quality efforts, documented in the provider’s policies.

Note: Providers of DD waiver services engaged in HCBS compliance efforts should include these in their QI program.

B. The QI program shall use standard tools, including root cause analysis, and include a QI plan.

Guidance:

12VAC35-105-20 defines a QI plan as a detailed, systematic work plan to review service quality and implement continuous, measurable improvements in services, supports, and health.

Revised.DBHDS, LIC16, November 2020 2

C. The quality improvement plan shall:

1. Be reviewed and updated at least annually;

Guidance:

No specific template is required; staff must review and update the QI plan at least annually (every 365 days).

Providers must update the plan more often if needed, especially after licensing reports, to ensure it addresses concerns and monitors CAPs. They should have a written evaluation plan.

The plan must specify responsible persons, documentation, and storage. It should be reviewed regularly, updated as needed, and signed with dates of implementation and updates.

1. Define measurable goals and objectives;

Guidance:

Goals and objectives should consider individuals served and services provided.

The QI plan should include measurable, operational goals with a monitoring schedule, e.g., reducing injuries by X% by a specific date.

This regulation does not require the provider to set a specific number of goals and objectives. Providers may wish to select only a few goals and then revise or expand the Revised.DBHDS, LIC16, November 2020 3

list as evaluations indicate. Providers collecting data already may consider using the data to identify areas for improvement. o For example, if data from fire drills indicates that it is taking longer to evacuate individuals than expected, the provider may set an objective to reduce the time to evacuate individuals from the facility from X minutes to Y minutes by [specific date]. Other goals and objectives could be tied to maintaining a well-trained workforce (i.e., objective of low turnover) or compliance with the HCBS settings requirements, if applicable. o Other examples of data driven objectives could include:
Increase the percentage of individuals with employment outcomes; or
Increase the percentage of individuals who participate in advocacy groups.

When setting goals, consider clarity, data sources, baseline, measurement frequency, success indicators, timelines, and accountability.

1. Include and report on statewide performance measures, if applicable, as required by

DBHDS;

Guidance:

Current statewide performance measures, developed by DBHDS Office of Developmental Services, apply only to licensed developmental service providers.

DBHDS will inform licensed providers of new statewide performance measures and reporting expectations if developed.

1. Monitor implementation and effectiveness of approved corrective action plans per 12VAC35-105-170;

Guidance:

The QI plan must include how to monitor CAP implementation, criteria for ending monitoring, and systematic actions to address deficiencies from citations or CAPs.

This includes setting measurable objectives linked to corrective actions and evaluating their achievement.

Revised.DBHDS, LIC16, November 2020 4

For example, a provider cited for medication errors can develop a CAP to reduce errors by X%, measured via chart review and reported in the QI program.

1. Include ongoing monitoring and evaluation of progress toward goals and objectives.

Guidance:

The QI program must specify how and when progress toward goals will be reviewed.

Reviews may be conducted via a regular quality council or structured meetings.

The process should evaluate goal achievement, revisions, and new initiatives to improve the QI plan.

Policies and procedures shall include criteria the provider will use to:

1. Establish measurable goals and objectives;

1. Update the provider’s quality improvement plan; and

1. Submit revised corrective action plans for approval or continue implementation with additional measures when a fully implemented plan fails to prevent recurrence or systemic deficiencies per 12VAC35-105-170.

Guidance:

Policies must detail how to develop, implement, and update the QI plan to ensure continuous improvement.

The provider’s policies must address steps when a fully implemented CAP fails to resolve the underlying issue, including continuing with additional measures or submitting a revised CAP for approval.

For additional information related to 12VAC35-105-620.D.2. and 12VAC35-105-170 please Revised.DBHDS, LIC16, November 2020 5

See DBHDS Office of Licensing’s Guidance on CAPs.

Input from individuals and their authorized representatives on services and participation satisfaction shall be part of the quality improvement plan, with improvements implemented when indicated.

Guidance:

Quality improvement programs must include input from individuals and authorized representatives on satisfaction and participation; indicated improvements shall be implemented.

Rev 6.7.21 1

2021 Person Centered ISP Guidance Provider Development Developmental Services Department of Behavioral Health and Developmental Services

June 7, 2021

Rev 6.7.21 2

2021 Person Centered ISP Guidance In response to the need for quality Person-Centered Individual Support Plans (PC ISPs) that meet all regulatory requirements and expectations, DBHDS is issuing the included guidance for writing and reviewing PC ISPs. The methods and practices described here are expected to lead to more success with person-centered planning. Specifically, the measurability of plans is needed for agreement with the Centers for Medicare and Medicaid (CMS) Home and Community Services (HCBS) Settings Regulations, the Settlement Agreement, and DBHDS licensing and developmental disability (DD) waiver regulations.

This paper details changes in thinking and writing to improve outcomes for people with DD Waivers in Virginia.

Measuring Progress In 2009, the principles of Person-Centered (PC) Practices became the foundation of Virginia’s Individual Support Plan in DD waivers. Over the past ten years, people with DD have been increasingly supported to make decisions about fundamental aspects of living in ways that matter most to them personally.

With the introduction of PC Practices, many providers and Support Coordinators (SCs) expressed appreciation for system changes that more fully implemented practices that they had long valued. The benefits of person-centered practices are evident, but we have struggled to develop person-centered plans that are specific to each person, retain the basics of accountability, and ultimately lead to meaningful changes in a person’s life.

At the center of the issue is a philosophical shift in how we plan with people. In moving from a deficit-based planning model to person-centered supports, the ability to show progress through planning has been strained. We have received reports from the independent reviewer for Virginia’s Settlement Agreement, from our state Medicaid agency, and from our licensing specialists that plans are not measurable. We can do better. To address these concerns, but maintain the core values of person-center practices, we have to find an effective and simple way to bring measurability to the plans we write with people. This paper has been written to detail how we believe planning can be both measurable and person-centered. It is offered as a means to establish common ground around person-centered planning for all DD stakeholders in Virginia.

“A test for something being person-centered is that it works for humans.” Michael Smull

In the 10th and 11th report to the court, the Independent Reviewer for the Settlement agreement stated that the most frequent shortcoming was that ISPs did not have specific and measurable outcomes (p.43). We have established the following processes to address this concern, while making every effort to stay true to the intent and spirit of person-centered practices.

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Virginia’s Person-Centered Individual Support Plan can be divided into three primary sections:

I.

The assessment: Part I Personal Profile and Part II Essential Information

II.

The plan for a desirable future: Part III Shared Planning and Part IV Agreements

III.

The action steps: Part V Plan for Supports When reviewing the PC ISP, it’s important to look across all parts to gain an understanding of how the plan supports the life the person wants. While it is an integrated whole where each section supports the others, the focus of this paper is on sections II and III listed above.

Shared Planning and Outcome Development Person-centered planning seeks to identify and achieve changes that bring a person more fully into his or her community and increase quality in the person’s life. In changing how we plan with people, we want to keep our values in place, which includes the person directing his process to the extent possible and being surrounded by people of his choosing. The person’s vision of a good life is what teams seek to uncover through conversations and in preparations for planning.

In the development of outcomes, it is important not to lose sight of the purpose of planning, discovering and setting in place plans to pursue the life the person wants. In shaping outcome statements, we recommend three considerations. Meaningful outcomes can support a person with achieving independence, integration, or an increased quality of life. As outcomes are developed, teams may benefit from asking if the outcome speaks to one of these three areas in determining if the outcome supports the person in a meaningful way.

We recognize that outcomes should be clearly stated and personally meaningful. For example, the idea that a person “increases independence in his life” is at the center of person-centered practices, but as an outcome it is not specific to an individual or easily observed. Planning teams should ask “how will this person increase independence in his life?” and “What does this mean to him?” Individual’s desired outcomes should be based on what is important to the person with regards to their personal preferences. As such, outcomes that stop with what’s important to the person often do not

Rev 6.7.21 4

result in observable statements that are specific to the person. For example, having more spending money might be important to a person, but in no way establishes what this means in measurable terms .

In addition to being observable, a few additional considerations can increase measurability of outcomes – the frequency of the outcome, the target date, and the steps that lead to the outcome.

For example, the statement “John has more money” can be improved by considering how this could describe an achievement that John would find meaningful such as: “John saves 50 dollars per month so that he can go on vacation next year” or “John earns at or above minimum wage for 12 months so that he has more shopping money.” Each outcome in the PC ISP will have a target date noted as “by when,” which indicates that the outcome is expected to be accomplished or will be reassessed by that date. When desired, a frequency should be included in the wording of the outcome statement.

Additional examples of measurable outcomes: Not measurable Measurable By when John does things.

John uses the post office in order to send a friend a card each month. 10/31/21 John goes places.

John vacations at the beach this year in order to see the ocean. 8/31/21 John meets people.

John goes to coffee shops weekly so that he meets new people. 10/31/21 John goes out to eat. John dines at a local restaurant at least weekly in order to enjoy a meal. 10/31/21 John feels good.

John uses his nebulizer as prescribed so that his breathing improves. 10/31/21

The next step for planners and teams to increase measurability is to describe the basic steps that lead to the outcome. These steps are shared across the planning team to contribute to achieving the outcome.

To make an outcome more measurable, we would ask what are the “key steps to get there.” These steps layout the plan to pursue the achievement, which is in line with action planning, a foundational practice in person-centered planning. These steps should be logical and when considered together be expected to result in the time-bound achievement that is defined in the outcome. Each step identifies the support or service that will assist with its accomplishment.

For example: Outcome End Date Key steps and services to get there… John vacations at the beach this year in order to see the ocean. 8/31/21 John chooses a location (day support), saves money (John’s brother), purchases supplies (day support), makes reservations (day support), and travels to the beach to see the ocean (in-home supports).

For support teams who struggle with forming outcomes, we have previously utilized a formula, which has been noted as helpful and should remain an option to support meaningful outcomes. This formula has been slightly modified as follows for the examples provided. The asterisk* is a reminder to include a frequency when desired: [Person’s name] [activity/event/important FOR]* so that/in order to [important TO achievement]

Rev 6.7.21 5

The following examples demonstrate the concept of formula use to develop outcomes: Important TO: Earning money Outcome (measurable achievement): John earns at least minimum wage monthly so that he has more shopping money.

Key steps and services to get there: Complete referral to DARS (SC), complete job development (supported employment), secure employment and learn job (supported employment) Important TO: Cooking dinner for family Outcome (measurable achievement): Jenny cooks Italian dinners for her family monthly in order to spend time with her family.

Key steps and services to get there: Menu planning, grocery shopping, inviting family, preparing and serving dinner (supported living) Important TO: Having more friends Outcome (measurable achievement): John goes to coffee shops weekly in order to meet new people.

Key steps and services to get there: Planning and going to coffee shops, sharing contact information, maintaining contact, (community engagement) developing comfort talking with new people (therapeutic consultation and community engagement) ,

Rev 6.7.21 6

Each of these examples shows movement from what’s important to the person to a more specific achievement that is time bound. Without this time bound element, there is decreased focus on making what is desired happen and it is more difficult to track success or establish progress toward the achievement. For example, if Jenny’s outcome was just to “prepare Italian dinners for her family” how would we know she is accomplishing this to the degree she wants? By including the time bound measure she wants as monthly, we have better defined what Jenny hopes to accomplish and what is considered by her and her support team to be achievable.

Outcomes may be changed or removed during the person-centered planning process, however if the outcome is part of what’s needed for the person to have the life he or she wants, there is no requirement to remove or change the outcome. Some supports will be needed across the lifespan whether they are provided by paid staff or natural supports. We need a planning process that brings about the positive changes desired by the person, while maintaining what is working and ensuring he or she is well supported in the routine course of daily life.

Balancing important TO and important FOR When developing outcomes, the team, which includes the person, should discuss the person’s preferences and the things that are important to them, as identified in the Personal Profile. In some instances, an outcome will directly reflect what is important for a person in addition to what is important to them. This helps to assure the whole support team is aware of identified behavioral and/or health needs in order to address associated risk factors and appropriately mitigate risk.

Identified health and behavioral support needs must be clearly included in planning. The inclusion of identified risks or “all essential supports” in plans is an additional concern identified by the Independent Reviewer for the Settlement Agreement in the 10th and 11th report (p.43). Adapting the completion of the Shared Plan as described above with “key steps to get there” listed under the “Key steps and services to get there…” section of the plan should help meet this requirement and reduce the chances key information is lost. The following example shows how multiple, related health supports can be addressed under a single outcome in the Shared Plan.

Rev 6.7.21 7

Important FOR: Insulin use, diabetic diet, blood sugar monitoring Important TO: Feeling good Outcome: Jill follows diabetic care each day so that she feels good.

Key steps and services to get there: Preparing diabetic-friendly meals and snacks (group home), taking insulin as prescribed, monitoring blood sugar, comfort check-ins (group home and skilled nursing) In this example, the activities needed to support Jill with diabetes are all included alongside the outcome. This method helps with grouping related supports and better ensures their inclusion in the component plans prepared by providers following the meeting. While these steps will be reflected in the support activities found in each of the support plans, not every provider will be expected to assist with each step. The support coordinator will assure that all steps are addressed across the support team in the various support plans.

Plans for Supports Support activities should be identified in the planning process as the basic steps in supporting the achievement of the outcomes, but will be more fully developed by providers following shared planning.

Support activities can be defined as being routine, for skill-development, for health and safety or to explore new opportunities before deciding on the specific nature of the activity. Support activities are developed with individuals by providers, and include action verbs that indicate what specific activities will be supported. Support activities may be groupings of activities (morning routine), but should also be written as individual activities when skills are being built, or when specific medical or behavioral protocols are being used (see examples below).

A basic formula for writing an activity statement is provided below. Each activity should use an action verb and be observable.

Support activity examples

Rev 6.7.21 8

Where skill-building is not being attempted, adding “how often” to the activity statement makes routine activities measurable.

Where skill-building is being attempted, more information is needed to determine that the person is developing skills as desired. Notice in the following examples “countable achievement” is used to describe the measure that will be used for each activity and each measure includes both how often and how long to help define the measure.

Routine measure examplesSkill-building measure examples

Rev 6.7.21 9

Criteria for the removal of supports for health and safety are based on healthcare guidelines, medical orders, or documented plans for removal.

When a measure is met, a new learning activity should be considered, explored, and attempted either by changing the skill or changing the measure. It is important to note that activities and sometimes outcomes may end simply because the person is no longer interested in pursuing the activity, or their needs may change such that the activity is no longer appropriate due to unforeseen circumstances. It is also possible – and actually likely – that some activities may be expected to last indefinitely and the person will continue to need the supports.

Support Instructions detail how the supports will be provided, in accordance with the individual’s needs and preferences, and how the individual will participate in the provision of supports. Ongoing noting in accordance with Medicaid requirements along with simplified data collection can assist providers with ongoing changes and quarterly reporting. While some support instructions may be “standard practice,” individualized person-centered instructions should also be woven throughout the plan.

In addition to Medicaid required noting, the following demonstrates data collection for each type of support:

Routine data exampleHealth & Safety measure examples

Rev 6.7.21 10

To illustrate how health and safety can be adequately addressed in planning, consider the following example: During the planning meeting, the team discusses Sophie’s diabetes. While the team all agrees that daily monitoring of her diabetes is absolutely necessary (important FOR), Sophie is only concerned with the fact that daily finger sticks are painful and what she wants is to be more comfortable (important TO).

Outcome: Sophie is more comfortable while testing her blood sugar each day so that she has less pain.

Key steps and services to get there…: Explore a new glucometer, test glucose daily (group home supports).

Support Activity: Sophie’s blood sugar levels are tested daily.

I no longer need or want support when (measure by providing a clearly stated achievement): Sophie’s physician removes the order for a daily finger sticks.

Support Instructions:

Staff conducts finger sticks every morning according to Sophie’s diabetes protocol (attached). Health & Safety data exampleSkill-building data example

Rev 6.7.21 11

Staff gently reminds Sophie that “it is time.” That is all that needs to be said, and she will know.

Saying “finger stick” upsets her.

Sophie chooses where to sit; some days she prefers being on her bed, and some days she prefers being on the lounge chair in the living room.

Staff puts smooth jazz music on the radio or tells a joke or a story to distract her during the finger stick.

If upon testing, Sophie’s blood sugar is lower than 80 mg/dl or higher than 120 mg/dl, take health and safety steps described in her protocol (attached).

What to record: Was Sophie’s blood sugar tested and recorded as stated in her plan (record any concerns in a note)? Yes; No It is clear in this example that the outcome is truly what is very important to Sophie to have in her life.

The support activity addresses the health need, and is clearly measurable, and the instructions are clear and reflective of both what Direct Support Professionals and Sophie will do.

Simply put, the outcome is “WHERE” we want to be, the support activities are “WHAT” we are doing to get there, and the support instructions are the “HOW” we are doing it. In a person-centered planning process, the person is at the center of planning. They let us know about the things they want in their lives; it is our role to support them in achieving what they want.

CMS specifically indicates in their guidance that person centered planning is not about “paper completion.” To that end, it may be helpful to envision the process out of order, that is, we are providing the supports (support activities) in this specific manner (support instructions) in order for the person to achieve what they want in their life (outcomes).

This guidance is offered as the basis of expectations as we move forward. Person-centered plans can be measurable and measurability helps to ensure that we are accountable to the people we support. For people to have more independence, more integration, and a better quality of life, we must live up to the promises we make in the planning process. We hope these adjustments lead to better planning and better lives for those we support.

Rev 6.7.21 12

Background Resources

DBHDS Office of Provider Development: https://dbhds.virginia.gov/developmental-services/provider-development DBHDS Office of Licensing: http://www.dbhds.virginia.gov/quality-management/Office-of-Licensing Helen Sanderson Associates: http://helensandersonassociates.co.uk/Independent Reviewers 10th and 11th report and the DOJ Settlement Agreement: http://www.dbhds.virginia.gov/doj-settlement-agreement The Learning Community for Person-Centered Practices: http://www.tlcpcp.comThe Oregon ISP: https://oregonisp.org/UMKC Institute for Human Development: http://www.lifecoursetools.com

12

Rev 6.7.21 1

2021 Person Centered ISP Guidance Developmental Services Department of Behavioral Health and Developmental Services

June 7, 2021

Rev 6.7.21 2

2021 Person Centered ISP Guidance In response to the need for quality Person-Centered Individual Support Plans (PC ISPs) that meet all regulatory requirements and expectations, DBHDS is issuing the included guidance for writing and reviewing PC ISPs. The methods and practices described here are expected to lead to more success with person-centered planning. Specifically, the measurability of plans is needed for agreement with the Centers for Medicare and Medicaid (CMS) Home and Community Services (HCBS) Settings Regulations, the Settlement Agreement, and DBHDS licensing and developmental disability (DD) waiver regulations.

This paper outlines changes to improve outcomes for people with DD Waivers in Virginia.

Since 2009, PC Principles have underpinned Virginia’s DD waiver ISPs, supporting people with DD to make decisions about key life aspects that matter most to them.

Support Coordinators and providers appreciated PC Practice system changes, but challenges remain in creating specific, accountable, and impactful person-centered plans.

The shift to person-centered planning strains progress measurement. Reports show plans are not measurable. This paper offers a simple way to make plans both measurable and person-centered, fostering common understanding among stakeholders.

“A test for person-centeredness is that it works for humans.” Michael Smull

The court reports noted ISPs lacked specific, measurable outcomes. We have implemented processes to address this while preserving person-centered intent.

Rev 6.7.21 3

Virginia’s Person-Centered Support Plan has three main sections:

I.

The assessment: Part I Personal Profile and Part II Essential Information

II.

The plan for a desirable future: Part III Shared Planning and Part IV Agreements

III.

Action steps: Part V Plan for Supports. When reviewing the PC ISP, consider all parts to understand how the plan supports the person’s desired life, focusing on sections II and III.

Shared Planning and Outcome Development aim to help individuals integrate into community and improve quality of life, with the person leading and choosing their support network, uncovered through conversations.

In the development of outcomes, it is important not to lose sight of the purpose of planning, discovering and setting in place plans to pursue the life the person wants. In shaping outcome statements, we recommend three considerations. Meaningful outcomes can support a person with achieving independence, integration, or an increased quality of life. As outcomes are developed, teams may benefit from asking if the outcome speaks to one of these three areas in determining if the outcome supports the person in a meaningful way.

We recognize that outcomes should be clearly stated and personally meaningful. For example, the idea that a person “increases independence in his life” is at the center of person-centered practices, but as an outcome it is not specific to an individual or easily observed. Planning teams should ask “how will this person increase independence in his life?” and “What does this mean to him?” Individual’s desired outcomes should be based on what is important to the person with regards to their personal preferences. As such, outcomes that stop with what’s important to the person often do not

Rev 6.7.21 4

result in observable statements that are specific to the person. For example, having more spending money might be important to a person, but in no way establishes what this means in measurable terms .

Measurability can be enhanced by considering outcome frequency, target date, and supporting steps.

To improve measurability, specify key steps, target dates (“by when”), and frequency if needed, e.g., “John saves $50/month to vacation” or “earns minimum wage for 12 months.”

Additional examples of measurable outcomes: Not measurable Measurable By when John does things.

John uses the post office in order to send a friend a card each month. 10/31/21 John goes places.

John vacations at the beach this year in order to see the ocean. 8/31/21 John meets people.

John goes to coffee shops weekly so that he meets new people. 10/31/21 John goes out to eat. John dines at a local restaurant at least weekly in order to enjoy a meal. 10/31/21 John feels good.

John uses his nebulizer as prescribed so that his breathing improves. 10/31/21

The next step for planners and teams to increase measurability is to describe the basic steps that lead to the outcome. These steps are shared across the planning team to contribute to achieving the outcome.

To make an outcome more measurable, we would ask what are the “key steps to get there.” These steps layout the plan to pursue the achievement, which is in line with action planning, a foundational practice in person-centered planning. These steps should be logical and when considered together be expected to result in the time-bound achievement that is defined in the outcome. Each step identifies the support or service that will assist with its accomplishment.

For example: Outcome End Date Key steps and services to get there… John vacations at the beach this year in order to see the ocean. 8/31/21 John chooses a location (day support), saves money (John’s brother), purchases supplies (day support), makes reservations (day support), and travels to the beach to see the ocean (in-home supports).

For support teams struggling with outcomes, we previously used a helpful formula, which remains an option. The formula is modified: [Person’s name] [activity/event/important FOR]* to achieve [important TO]

Rev 6.7.21 5

Examples show formula use for outcomes: Important TO: Earning money. Outcome: John earns minimum wage monthly to have more shopping money.

Key steps: Refer to DARS (SC), develop job, secure employment, learn job. Important TO: Cooking dinner for family. Outcome: Jenny cooks Italian dinners monthly to spend time with family.

Key steps: Menu planning, shopping, inviting, preparing, serving dinner. Important TO: Having more friends. Outcome: John visits coffee shops weekly to meet new people.

Key steps: Plan and visit coffee shops, share contact info, maintain contact, develop comfort talking with new people (community engagement, therapy).

Rev 6.7.21 6

Examples show moving from what’s important to a specific, time-bound achievement. Without time bounds, tracking success is harder. For Jenny, monthly Italian dinners clarify goals.

Outcomes may be changed or removed during the person-centered planning process, however if the outcome is part of what’s needed for the person to have the life he or she wants, there is no requirement to remove or change the outcome. Some supports will be needed across the lifespan whether they are provided by paid staff or natural supports. We need a planning process that brings about the positive changes desired by the person, while maintaining what is working and ensuring he or she is well supported in the routine course of daily life.

Balancing important TO and important FOR When developing outcomes, the team, which includes the person, should discuss the person’s preferences and the things that are important to them, as identified in the Personal Profile. In some instances, an outcome will directly reflect what is important for a person in addition to what is important to them. This helps to assure the whole support team is aware of identified behavioral and/or health needs in order to address associated risk factors and appropriately mitigate risk.

Identified health and behavioral support needs must be clearly included in planning. The inclusion of identified risks or “all essential supports” in plans is an additional concern identified by the Independent Reviewer for the Settlement Agreement in the 10th and 11th report (p.43). Adapting the completion of the Shared Plan as described above with “key steps to get there” listed under the “Key steps and services to get there…” section of the plan should help meet this requirement and reduce the chances key information is lost. The following example shows how multiple, related health supports can be addressed under a single outcome in the Shared Plan.

Rev 6.7.21 7

Important FOR: Insulin, diabetic diet, blood sugar monitoring. Important TO: Feeling good. Outcome: Jill follows diabetic care daily to feel good.

Key steps and services to get there: Preparing diabetic-friendly meals and snacks (group home), taking insulin as prescribed, monitoring blood sugar, comfort check-ins (group home and skilled nursing) In this example, the activities needed to support Jill with diabetes are all included alongside the outcome. This method helps with grouping related supports and better ensures their inclusion in the component plans prepared by providers following the meeting. While these steps will be reflected in the support activities found in each of the support plans, not every provider will be expected to assist with each step. The support coordinator will assure that all steps are addressed across the support team in the various support plans.

Support activities should be identified during planning as basic steps toward outcomes, then fully developed by providers after shared planning.

Support activities can be defined as being routine, for skill-development, for health and safety or to explore new opportunities before deciding on the specific nature of the activity. Support activities are developed with individuals by providers, and include action verbs that indicate what specific activities will be supported. Support activities may be groupings of activities (morning routine), but should also be written as individual activities when skills are being built, or when specific medical or behavioral protocols are being used (see examples below).

A basic formula for activity statements: use action verbs and ensure observability.

Support activity examples

Rev 6.7.21 8

For non-skill activities, adding “how often” makes routines measurable.

For skill-building, more info is needed to show skill development. Examples use “countable achievement,” including frequency and duration, to define measures.

Routine measure examplesSkill-building measure examples

Rev 6.7.21 9

Support removal criteria are based on healthcare guidelines, medical orders, or documented plans.

When a measure is met, a new learning activity should be considered, explored, and attempted either by changing the skill or changing the measure. It is important to note that activities and sometimes outcomes may end simply because the person is no longer interested in pursuing the activity, or their needs may change such that the activity is no longer appropriate due to unforeseen circumstances. It is also possible – and actually likely – that some activities may be expected to last indefinitely and the person will continue to need the supports.

Support Instructions specify support provision per individual needs and participation. Ongoing Medicaid-compliant notes and data aid updates. Individualized instructions should be integrated throughout the plan.

Besides Medicaid notes, the following shows data collection for support types:

Routine data exampleHealth & Safety measure examples

Rev 6.7.21 10

To illustrate how health and safety can be adequately addressed in planning, consider the following example: During the planning meeting, the team discusses Sophie’s diabetes. While the team all agrees that daily monitoring of her diabetes is absolutely necessary (important FOR), Sophie is only concerned with the fact that daily finger sticks are painful and what she wants is to be more comfortable (important TO).

Outcome: Sophie is more comfortable testing her blood sugar daily to reduce pain.

Key steps: Explore a new glucometer, test glucose daily (group home supports).

Support Activity: Sophie’s blood sugar levels are tested daily.

Support ends when Sophie’s physician removes the order for daily finger sticks (measured by achievement).

Support Instructions:

Staff conducts finger sticks every morning according to Sophie’s diabetes protocol (attached). Health & Safety data exampleSkill-building data example

Rev 6.7.21 11

Staff gently reminds Sophie that “it is time.” That is all that needs to be said, and she will know.

Saying “finger stick” upsets her.

Sophie chooses her seat; some days on her bed, others on the lounge chair in the living room.

Staff plays jazz or tells jokes/stories to distract her during finger sticks.

If blood sugar is below 80 mg/dl or above 120 mg/dl, follow her protocol (attached).

Record: Was Sophie’s blood sugar tested and recorded per her plan (note concerns)? Yes/No. The outcome is what matters most to Sophie.

Support activity addresses health needs, is measurable, and instructions are clear for DSPs and Sophie.

Simply put, the outcome is “WHERE” we want to be, the support activities are “WHAT” we are doing to get there, and the support instructions are the “HOW” we are doing it. In a person-centered planning process, the person is at the center of planning. They let us know about the things they want in their lives; it is our role to support them in achieving what they want.

CMS specifically indicates in their guidance that person centered planning is not about “paper completion.” To that end, it may be helpful to envision the process out of order, that is, we are providing the supports (support activities) in this specific manner (support instructions) in order for the person to achieve what they want in their life (outcomes).

This guidance sets expectations. Measurable plans ensure accountability, promoting independence, integration, and quality of life. These changes aim for improved planning and lives.

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Background Resources

Resources: DBHDS Provider Development, Licensing, Helen Sanderson Associates, Reviewers & DOJ, Person-Centered Practices, Oregon ISP, UMKC Institute.

12

Direct Support Professional (DSP) and DSP Supervisor DD Waiver Orientation and Competencies Protocol March 6, 2020

DBHDS DSP and DSP Supervisor DDW Orientation and Competencies Protocol 3.6.20 Page 2 of 11

Introduction Direct Support Professionals (DSPs) and their supervisors who provide services and supports for people with developmental disability (DD) in Virginia are required to complete an orientation training process established by the Department of Behavioral Health and Developmental Services (DBHDS) per Medicaid Waiver regulations (12VAC30-122-180). This process was initiated in 1997 and has seen various revisions and updates since that time. It is designed with three purposes in mind: so people get quality services, to build skills and confidence, and to enhance the supervisor-DSP relationship.

This protocol serves as a resource to providers in understanding the competency-based training requirements of Virginia’s Developmental Disability Waivers (i.e. the Building Independence Waiver, the Family and Individual Supports Waiver, and the Community Living Waiver). This process does not replace the requirements for providers to meet DBHDS training and orientation requirements under the DBHDS Office of Licensing, which are described in the DBHDS Licensing Regulations (12VAC35-105-440,450) or other regulations or accreditation standards.

Defining Direct Support Professional (DSP) Direct Support Professional (DSP) is defined under the DD waivers as: "Direct support professional," "direct care staff," or "DSP" means staff members identified by the provider as having the primary role of assisting an individual on a day-to-day basis with routine personal care needs, social support, and physical assistance in a wide range of daily living activities so that the individual can lead a self-directed life in his own community. This term shall exclude consumer-directed staff and services facilitation providers.

Any agency employee, regardless of credentials, who provides Medicaid Waiver reimbursable support as described above, must complete the DBHDS DSP Orientation process. This process also applies to supervisors who oversee the work of DSPs. Providers may elect to employ agency trainers in delivering training content to DSPs and their supervisors, which is acceptable, but the use of a trainer does not supplant conversations between DSPs and supervisors about the content of the training or the application of that content within the provider setting.

This process does not apply to professional staff who provide consultative or specialized medical and behavioral support, such as Therapeutic Consultation, Skilled Nursing, and Private Duty Nursing.

Providers of Individual and Group Supported Employment services were previously excluded due to operating within organizations that met Commission on Accreditation of Rehabilitation Facilities (CARF) standards. Employment Service Organizations are now required to complete orientation training, testing, and to observe and document basic competencies per Settlement Agreement (SA) negotiations with the Department of Justice, which occurred in January of 2020. In addition, DMAS enrolled Home Care Organizations licensed by the Virginia Department of Health who are providing Personal Assistance, Respite, and Companion under any DD Waiver must implement the process of observing and documenting competencies as described in this protocol in addition to completing the training and testing requirements per the same SA negotiations .

DBHDS DSP and DSP Supervisor DDW Orientation and Competencies Protocol 3.6.20 Page 3 of 11

There is a set of requirements that affect all providers of specified waiver services and one additional set of advanced competency requirements for DBHDS-licensed providers only, which are dependent upon who is being supported.

DSP and DSP Supervisor Orientation Training; Testing; Assurances Agencies providing direct support to individuals on the Developmental Disabilities' waivers are required to complete the DSP Orientation training. This includes both non-DBHDS licensed providers (such as Home Care Organizations licensed by the Virginia Department of Health and Employment Services Organizations under the Department of Aging and Rehabilitative Services) in addition to DBHDS-licensed providers.

These requirements apply to all providers of the following services:

 Agency-Directed Personal Assistance  Agency-Directed Companion  Agency-Directed Respite  Center-based Crisis Services  Community-based Crisis Services  Crisis Support Services  Community Engagement  Community Coaching  Group Day Services  Group Home Residential  Group Supported Employment  Independent Living  In-Home Support Services  Individual Supported Employment  Sponsored Residential  Supported Living Residential  Workplace Assistance Supervisor-specific Requirements

DSP supervisors in agencies providing any of the above services must complete online training and testing through the Commonwealth of Virginia Learning Center (VLC), which is a web-based application that delivers self-study training topics to Virginia employees, Community Services Boards, and community providers.

The VLC provides supervisors with the online supervisor’s training and competency test. This online training provides information about the role of a DSP supervisor under these requirements, the expectations for implementing the orientation process, and provides a certificate of completion that must be retained in the personnel file for programmatic review by the DBHDS Office of Licensing and the Department of Medical Assistance Services.

Supervisors can access the required supervisor training and take the test through the Virginia Learning Center (VLC). Access the VLC online by following this guide: DBHDS External Entities Domain Guide. The supervisor training can be located in the VLC by searching with the key word “DSP”.

Once a supervisor has completed online training and testing through the VLC, they may request a copy of the DSP test answer key by sending a copy of their VLC certificate to their assigned Community Resource Consultant with DBHDS: Provider Development Contact Chart.

Linked resources are maintained online at: http://www.dbhds.virginia.gov/developmental-services/provider-development.

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The following chart illustrates supervisor-specific requirements:

Orientation Manual and Training Slides

Direct Support Professionals follow a different process from supervisors in completing orientation training and competency testing. DSPs receive training from their agency supervisor or designated agency trainer. They may also access the training materials through a public facing website, which includes a manual, training slides for agency use, and the various forms and checklists related to these requirements. Use of the materials is encouraged as they contain content that is freely available to providers and align with Virginia’s principles, values, and expectations for providing support under the DD waivers. The Orientation Manual and training slides that may be used in equipping DSPs with necessary knowledge, skills and abilities are available online at:

https://partnership.vcu.edu/DSP_orientation/index.html

The Orientation Manual Test is divided across the six areas contained in the DSP Orientation Manual:

Section I: The Values that Support Life in the Community Section II: Introduction to Developmental Disabilities Section III: Waivers for People with Developmental Disabilities Section IV: Communication Section V: Positive Behavioral Support Section VI: Health and Safety

The Orientation Manual was designed:

 To outline the current values and best practices associated with providing Developmental Disability Waiver services and supports

 To provide DSPs and supervisors with practical tips on how to apply these values and better support individuals with intellectual and other disabilities

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 To prepare DSPs and supervisors who come with varying degrees of experience, for the work ahead of them

 To promote person-centered service delivery

Assurances

DSPs (and DSP supervisors) must also confirm through a signed assurance that they have met the competency-based training requirements and passed the “Orientation Manual Test” with at least 80% success prior to providing reimbursable supports in the absence of other staff who have successfully completed requirements.

The signed assurance confirms the receipt of instruction in the characteristics of developmental disabilities and Virginia’s DD Waivers, person-centeredness, positive behavioral supports, effective communication, DBHDS-identified health risks and the appropriate interventions, and best practices in the support of individuals with developmental disabilities.

Assurance documents are specific to agency role. There are two versions and DSPs and DSP supervisors complete the version that matches their role within the organization. A copy of the Orientation Manual test and these assurance documents are available online at:

https://partnership.vcu.edu/DSP_orientation/Competencies-Assurances-Tests.html.

The assurances include confirmation of the use of observational competency checklists, which will be covered in the next sections of this protocol.

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DSP & DSP Supervisor Basic Competency Checklist

All DSPs and DSP Supervisors providing the services described in this document (see page 2) must complete an observed competency checklist that records DSP and DSP supervisors’ ability to be proficient in three established competencies. Each competency has a set of skills that are observed and documented during the 180 day orientation period for new DSPs and DSP Supervisors. The skills under the third competency, must be confirmed at a “competent” level of ability prior to providing these supports in the absence of staff who have been deemed proficient with these skills. The three competencies are:

1. Demonstrates person-centered skills, values and attitudes,
2. Understands and follows service requirements, and
3. Demonstrates abilities that improve or maintain the health and wellness of those they support.

These competencies and the type (i.e. 1:1, group, and/or formal education) of any related training (such as reviewing the DBHDS provider DSP training manual and slides) are documented on a standard checklist (DMAS #P241a). Observation of DSPs applying their knowledge and skills is documented by DSP Supervisors. DSP supervisors’ observation and documentation is completed by the agency Director or designee. This checklist is introduced with two pages of instruction to assist in consistent application across DSPs and DSP Supervisors. Levels of ability recorded on the checklist are defined as follows:

• Basic understanding: The individual is able to communicate a fundamental knowledge of the skill or action; high level of supervision needed.
• Developing: The individual is in the process of establishing the ability or is showing some, but not all, aspects of the skill or action in practice; moderate level of supervision needed.
• Competent: The individual demonstrates all applicable skills or actions in column two, but not on a routine basis as appropriate to the skill or action; low level of supervision needed. Competency refers to the minimum required for acceptability.
• Proficiency: The individual demonstrates all aspects of the skill or action on a routine basis in practice as appropriate to the skill or action; minimal supervision needed. Proficiency establishes an ongoing level of ability that is above the minimum.

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The checklist instructions contain critical information about the process including:

DSPs and supervisors are deemed proficient once all related skills and behaviors have been observed and documented on the checklist, including noting as not applicable (NA) if an action related to any skill does not apply in the current role in any of the skills included on the checklist. Proficiency is established when the skills are observed over time and each area must be confirmed as proficient within 180 days of hire.

To ensure the health and wellness of people receiving services, Competency 3 and all related skills must be confirmed as competent prior to providing support in the absence of paid staff who has demonstrated proficiency with this competency. Competency refers to the bare minimum required for acceptability where proficiency establishes an ongoing level of ability that is above the minimum.

If at any time a DSP or DSP Supervisor is found to be deficient in any competency area, billing by the agency must cease related to those services rendered by that person. The provider must document actions taken and the date that restoration of ability is confirmed. Once proficiency has been demonstrated, the provider may resume billing for services provided by the DSP or supervisor from that date forward. DMAS shall not reimburse for those services provided by DSPs or DSP supervisors who have failed to pass the orientation test or demonstrate competencies as required.

The initial completion of the checklist and annual updates, as well as confirmation of training, must be maintained and available for review by the Department of Behavioral Health and Developmental Services, the Department of Medical Assistance Services, and other reviewers as required.

Virginia’s Competencies for Direct Support Professionals and Supervisors who support individuals with Developmental Disabilities checklist is available online at: https://partnership.vcu.edu/DSP_orientation/Competencies-Assurances-Tests.html

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DSP & DSP Supervisor Advanced Competency Checklists and Training for DBHDS-licensed Agencies Only

While Virginia’s Competencies for Direct Support Professionals and Supervisors who support individuals with Developmental Disabilities checklist applies to DBDHS-licensed agencies supporting people from Supports Intensity Scale SIS© tiers one through four, there are additional training requirements and competency checklists when providers support people most at risk and identified as having support needs defined through the SIS© at tier four.

DBHDS established training and competency requirements as described in the 2016 DMAS Medicaid Memo to include a higher level of skill when providers offer services and supports to people with tier four support needs. Included in DD Waiver regulations (12VAC30-122-180) and the Medicaid Memo

1. 1.16, are the requirements that providers supporting individuals at SIS© tier four complete training in the areas of autism, complex health supports, and complex behavioral supports.

Training in these areas can be developed or reviewed and approved by a qualified professional in each area as described in the DBHDS Advanced Competencies Training Topics 9.25.17 document available online here: https://partnership.vcu.edu/DSP_orientation/Competencies-Assurances-Tests.html.

Training may be accessed through a variety of means as long as it is nationally recognized or developed or approved by a qualified professional in each competency area.

Health professionals include: a physician, nurse practitioner, psychiatric nurse practitioner, or registered nurse (RN).

Autism professionals include: a psychiatrist; a psychologist; psychiatric nurse practitioner; a Licensed Professional Counselor (LPC); a Licensed Clinical Social Worker (LCSW); a Psychiatric Clinical Nurse Specialist, or a Certified Autism Specialist (CAS), a Licensed Behavior Analyst (LBA), or a Licensed Assistant Behavior Analyst (LABA).

Behavioral professionals include: a psychiatrist; a psychologist; psychiatric nurse practitioner; a Licensed Professional Counselor (LPC); a Licensed Clinical Social Worker (LCSW); a Psychiatric Clinical Nurse Specialist, Positive Behavioral Support Facilitator (PBSF), a Licensed Behavior Analyst (LBA), or a Licensed Assistant Behavior Analyst (LABA).

The following topics must be included in training provided to DSPs and their supervisors when supporting individuals at SIS© tier four:

Health: Confidentiality; Professional collaboration; Communicating health information; Documenting health information; Relationship between physical and mental health; Common risk factors for DD-related health conditions; Universal precaution procedures; Performing delegated tasks; Supporting Virginia’s identified risks for people with DD including: skin care (pressure sores; skin breakdown), aspiration pneumonia, falls, urinary tract infections, dehydration, constipation & bowel obstruction, sepsis, and seizures; Providing direct care to individuals with complex health care needs (e.g. ADL's, positioning, care of Durable Medical Equipment, and specialized supervision with appropriate responses to health parameters set by the health professional.

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Behavior: Ethical Practices (practicing within scope); Function and Purpose of Behavior; Replacement Behavior Training; Positive Behavior Supports; Behavioral Prevention; Dual Diagnosis; Data Collection (goal and purpose); Ruling out medical concerns for behavior.

Autism: General Characteristics of Autism; Dual Diagnosis; Environmental Modifications/Assessments; Communication Supports and Strategies; Social skills, Peer Interactions, and Friendship; Sensory Integration; Life Span Supports.

There are three corresponding advanced competency checklists that must be completed in DBHDS-licensed programs (see page 2 for included services) where individuals with SIS© tier four support needs receive services and supports from DSPs and DSP supervisors based on individual needs. These include:

Virginia’s Autism Competencies for Direct Support Professionals and Supervisors who support individuals with Developmental Disabilities (DMAS #P201)

Virginia’s Health Competencies for Direct Support Professionals and Supervisors who support individuals with Developmental Disabilities (DMAS #P244a)

Virginia’s Behavioral Competencies for Direct Support Professionals and Supervisors who support individuals with Developmental Disabilities (DMAS #P240a)

Criteria for Requiring Advanced Competencies at SIS® Tier Four Health The presence of a complex health condition that necessitates specific supports and instructions indicates that Health Competencies (DMAS P244a) must be met.

Autism A diagnosis of autism indicates that Autism Competencies (DMAS P201a) must be met.

Behavioral The need for behavioral supports either in the ISP or in a formal behavioral plan indicates that Behavioral Supports Competencies (DMAS P240a) must be met.

These advanced competency checklists are available online at: https://partnership.vcu.edu/DSP_orientation/Competencies-Assurances-Tests.html

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These checklists must be initiated by DBHDS-licensed providers and DSPs and DSP supervisors confirmed as proficient within 180 days of hire or within 180 days of assisting a person with related SIS© tier four support needs whether that person is new to the program or receives an updated SIS© confirming Tier Four, which corresponds with SIS© levels 5, 6, and 7. The checklists would be limited to those that are relevant to the needs of the individual(s) supported. DBHDS Licensing regulations require that providers admit only those individuals whose service needs are consistent with the service description, for whom services are available, and for which staffing levels and types meet the needs of the individuals served receiving services (12VAC35-105-580). These advanced competencies build on these requirements and are designed to increase consistency in the support offered through these programs.

Compliance, Data, and Provider Remediation

Provider agencies are reviewed by DMAS Quality Management Review (QMR) for compliance with DSP and DSP Supervisor competency training requirements. If upon review a provider does not have documentation to demonstrate that DSPs and DSP Supervisors have met the requirements set forth in this protocol per DD Waiver regulations, the provider will be cited for a lack of compliance with waiver requirements. Providers must respond through a corrective action plan when deficiencies are identified by DMAS that details the methods that will be employed to ensure ongoing, sustained implementation of these requirements. A provider’s inability to demonstrate compliance can result in a provider having its DMAS participation agreement or DBHDS license suspended or revoked.

DBHDS and DMAS collect data around compliance and remediation activities related to this process, which is part of Virginia’s overall approach to compliance under the waivers per approval by the Centers for Medicare and Medicaid Services at the federal level.

The established measures included in DD Waiver Quality Assurance Reporting for these requirements and that are currently tracked for compliance are stated as:

Number and percent of provider agency staff meeting provider orientation training requirements.

Number and percent of provider agency direct support professionals (DSPs) meeting competency training requirements.

Completed at Level 1

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Through these measures DBHDS and DMAS report to CMS the number of providers who meet and do not meet provider orientation training requirements. This is one means of determining Virginia’s success with operating the Building Independence, Family & Individual Supports, and Community Living Waivers.

Portability

DSPs who move employment from one agency to another and have documentation of having completed training and passed the 2016 Orientation Manual Test there do not have to be retrained, although the new agency would still discuss the values and concepts as they pertain to their agency’s policies with the new employee. The new provider would ensure that receipt of a copy of the DSP’s scored test or supervisor’s VLC certificate and assurance and keep it on file. Competencies where required must be confirmed at each agency within 180 days of hire and reconfirmed at least annually.

Questions about these requirements can be directed to your assigned Community Resource Consultant.

A contact list and linked documents are available online at the DBHDS Provider Development Webpage: http://www.dbhds.virginia.gov/developmental-services/provider-development.

Documentation Requirements Overview

Direct Support Professional (DSP) and DSP Supervisor DD Waiver Orientation and Competencies Protocol March 6, 2020

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Introduction Direct Support Professionals (DSPs) and their supervisors who provide services and supports for people with developmental disability (DD) in Virginia are required to complete an orientation training process established by the Department of Behavioral Health and Developmental Services (DBHDS) per Medicaid Waiver regulations (12VAC30-122-180). This process was initiated in 1997 and has seen various revisions and updates since that time. It is designed with three purposes in mind: so people get quality services, to build skills and confidence, and to enhance the supervisor-DSP relationship.

This protocol helps providers understand competency training for Virginia’s DD Waivers (Building Independence, Family and Individual Supports, Community Living). It does not replace DBHDS licensing or other regulatory requirements (12VAC35-105-440,450).

DSP is defined as staff assisting individuals daily with personal care, social support, and physical help to enable self-directed living, excluding consumer-directed staff and services facilitators.

All agency employees providing Medicaid Waiver support must complete DBHDS DSP Orientation. Supervisors overseeing DSPs must also complete it. Trainers may be used but do not replace supervisor-DSP discussions.

This process excludes professional staff providing consultative or specialized medical/behavioral support, e.g., Therapeutic Consultation, Skilled Nursing, Private Duty Nursing.

Providers of Individual and Group Supported Employment services were previously excluded due to operating within organizations that met Commission on Accreditation of Rehabilitation Facilities (CARF) standards. Employment Service Organizations are now required to complete orientation training, testing, and to observe and document basic competencies per Settlement Agreement (SA) negotiations with the Department of Justice, which occurred in January of 2020. In addition, DMAS enrolled Home Care Organizations licensed by the Virginia Department of Health who are providing Personal Assistance, Respite, and Companion under any DD Waiver must implement the process of observing and documenting competencies as described in this protocol in addition to completing the training and testing requirements per the same SA negotiations .

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All providers of specified waiver services must meet basic requirements; DBHDS-licensed providers have additional advanced competency requirements based on the supported individual.

All agencies providing direct support on DD waivers must complete DSP Orientation training and testing, including non-DBHDS licensed providers like Home Care and Aging and Rehabilitative Services organizations.

These requirements apply to all providers of the following services:

Includes Agency-Directed Personal Assistance, Companion, Respite; Center and Community Crisis Services; Crisis Support; Community Engagement; Coaching; Group Day, Residential, Supported Employment, Independent Living, In-Home Support, Sponsored Residential, Supported Living, Workplace Assistance; Supervisor-specific requirements.

Supervisors of agencies providing these services must complete online training and testing via the Virginia Learning Center (VLC), a web-based self-study platform.

VLC offers online supervisor training, competency test, and a certificate of completion to be kept in personnel files for review by DBHDS Licensing and DMAS.

Supervisors can access the required supervisor training and take the test through the Virginia Learning Center (VLC). Access the VLC online by following this guide: DBHDS External Entities Domain Guide. The supervisor training can be located in the VLC by searching with the key word “DSP”.

After completing VLC training and testing, supervisors may request the DSP test answer key by sending their VLC certificate to their DBHDS Community Resource Consultant: Provider Development Contact Chart.

Linked resources are maintained online at: http://www.dbhds.virginia.gov/developmental-services/provider-development.

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The following chart illustrates supervisor-specific requirements:

Orientation Manual and Training Slides

Direct Support Professionals follow a different process from supervisors in completing orientation training and competency testing. DSPs receive training from their agency supervisor or designated agency trainer. They may also access the training materials through a public facing website, which includes a manual, training slides for agency use, and the various forms and checklists related to these requirements. Use of the materials is encouraged as they contain content that is freely available to providers and align with Virginia’s principles, values, and expectations for providing support under the DD waivers. The Orientation Manual and training slides that may be used in equipping DSPs with necessary knowledge, skills and abilities are available online at:

https://partnership.vcu.edu/DSP_orientation/index.html

The Orientation Manual Test covers six areas in the DSP Orientation Manual:

Sections: I. Values Supporting Community Life; II. Introduction to Developmental Disabilities; III. Waivers for People with DD; IV. Communication; V. Positive Behavioral Support; VI. Health and Safety.

The Orientation Manual was designed:

 To outline the current values and best practices associated with providing Developmental Disability Waiver services and supports

To give DSPs and supervisors practical tips for applying values and supporting individuals with disabilities.

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To prepare DSPs and supervisors with varying experience levels for their work.

To promote person-centered services.

Assurances

DSPs and supervisors must sign an assurance confirming they met training requirements and passed the Orientation Manual Test with at least 80% before providing reimbursable supports without staff who have completed requirements.

The assurance confirms instruction in developmental disabilities, Virginia’s DD Waivers, person-centeredness, positive supports, communication, health risks, interventions, and best practices.

Assurance documents are role-specific; DSPs and supervisors complete the version matching their role. Copies of the manual test and assurances are online at:

https://partnership.vcu.edu/DSP_orientation/Competencies-Assurances-Tests.html.

Assurances confirm use of observational competency checklists, covered in subsequent protocol sections.

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DSP & DSP Supervisor Basic Competency Checklist

All DSPs and Supervisors must complete an observed competency checklist for three competencies during the 180-day orientation. Skills under the third must be confirmed as competent before support in staff absence. The competencies are:

1. Demonstrates person-centered skills, values and attitudes,
2. Understands and follows service requirements, and
3. Demonstrates abilities that improve or maintain the health and wellness of those they support.

These competencies and the type (i.e. 1:1, group, and/or formal education) of any related training (such as reviewing the DBHDS provider DSP training manual and slides) are documented on a standard checklist (DMAS #P241a). Observation of DSPs applying their knowledge and skills is documented by DSP Supervisors. DSP supervisors’ observation and documentation is completed by the agency Director or designee. This checklist is introduced with two pages of instruction to assist in consistent application across DSPs and DSP Supervisors. Levels of ability recorded on the checklist are defined as follows:

• Basic understanding: individual can communicate fundamental knowledge of the skill or action; high supervision needed.
• Developing: The individual is establishing or showing some aspects of the skill in practice; moderate supervision needed.
• Competent: The individual demonstrates all skills in column two, but not routinely; low supervision needed. Competency is the minimum for acceptability.
• Proficiency: The individual demonstrates all aspects of the skill or action on a routine basis in practice as appropriate to the skill or action; minimal supervision needed. Proficiency establishes an ongoing level of ability that is above the minimum.

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Checklist instructions contain critical process information including:

DSPs and supervisors are proficient once all skills and behaviors are observed and documented, including NA if applicable. Proficiency must be confirmed within 180 days of hire.

To ensure health and wellness, Competency 3 and related skills must be confirmed competent before support in staff absence. Competency is the minimum; proficiency is above minimum.

If at any time a DSP or DSP Supervisor is found to be deficient in any competency area, billing by the agency must cease related to those services rendered by that person. The provider must document actions taken and the date that restoration of ability is confirmed. Once proficiency has been demonstrated, the provider may resume billing for services provided by the DSP or supervisor from that date forward. DMAS shall not reimburse for those services provided by DSPs or DSP supervisors who have failed to pass the orientation test or demonstrate competencies as required.

Initial and annual checklist completion, training confirmation, must be maintained and available for review by DBHDS, DMAS, and other reviewers.

Virginia’s Competencies for DSPs and Supervisors supporting individuals with Developmental Disabilities are available online at: https://partnership.vcu.edu/DSP_orientation/Competencies-Assurances-Tests.html

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DSP & DSP Supervisor Advanced Competency Checklists and Training for DBHDS-licensed Agencies Only

While applicable to DBDHS-licensed agencies supporting SIS© tiers one through four, additional training and competency checklists are required for support at tier four for at-risk individuals.

DBHDS training and competency requirements, per 2016 DMAS Medicaid Memo, include higher skills for tier four support needs, as in DD Waiver regulations (12VAC30-122-180).

1. 1.16: Providers supporting individuals at SIS© tier four must complete training in autism, complex health supports, and complex behavioral supports.

Training can be developed, reviewed, and approved by qualified professionals as outlined in the DBHDS Advanced Competencies Training Topics 9.25.17, available online at: https://partnership.vcu.edu/DSP_orientation/Competencies-Assurances-Tests.html.

Training must be nationally recognized or developed/approved by qualified professionals in each competency area.

Health professionals include: a physician, nurse practitioner, psychiatric nurse practitioner, or registered nurse (RN).

Autism professionals include: a psychiatrist; a psychologist; psychiatric nurse practitioner; a Licensed Professional Counselor (LPC); a Licensed Clinical Social Worker (LCSW); a Psychiatric Clinical Nurse Specialist, or a Certified Autism Specialist (CAS), a Licensed Behavior Analyst (LBA), or a Licensed Assistant Behavior Analyst (LABA).

Behavioral professionals include: a psychiatrist; a psychologist; psychiatric nurse practitioner; a Licensed Professional Counselor (LPC); a Licensed Clinical Social Worker (LCSW); a Psychiatric Clinical Nurse Specialist, Positive Behavioral Support Facilitator (PBSF), a Licensed Behavior Analyst (LBA), or a Licensed Assistant Behavior Analyst (LABA).

Training topics for DSPs and supervisors supporting SIS© tier four include:

Health: Confidentiality; Professional collaboration; Communicating health information; Documenting health information; Relationship between physical and mental health; Common risk factors for DD-related health conditions; Universal precaution procedures; Performing delegated tasks; Supporting Virginia’s identified risks for people with DD including: skin care (pressure sores; skin breakdown), aspiration pneumonia, falls, urinary tract infections, dehydration, constipation & bowel obstruction, sepsis, and seizures; Providing direct care to individuals with complex health care needs (e.g. ADL's, positioning, care of Durable Medical Equipment, and specialized supervision with appropriate responses to health parameters set by the health professional.

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Behavior: Ethical Practices (practicing within scope); Function and Purpose of Behavior; Replacement Behavior Training; Positive Behavior Supports; Behavioral Prevention; Dual Diagnosis; Data Collection (goal and purpose); Ruling out medical concerns for behavior.

Autism: General Characteristics of Autism; Dual Diagnosis; Environmental Modifications/Assessments; Communication Supports and Strategies; Social skills, Peer Interactions, and Friendship; Sensory Integration; Life Span Supports.

There are three corresponding advanced competency checklists that must be completed in DBHDS-licensed programs (see page 2 for included services) where individuals with SIS© tier four support needs receive services and supports from DSPs and DSP supervisors based on individual needs. These include:

Virginia’s Autism Competencies for DSPs and Supervisors supporting individuals with Developmental Disabilities (DMAS #P201)

Virginia’s Health Competencies for Direct Support Professionals and Supervisors who support individuals with Developmental Disabilities (DMAS #P244a)

Virginia’s Behavioral Competencies for Direct Support Professionals and Supervisors who support individuals with Developmental Disabilities (DMAS #P240a)

Criteria for SIS® Tier Four Health Advanced Competencies: presence of complex health condition requiring specific supports and instructions mandates Health Competencies (DMAS P244a).

Autism diagnosis requires Autism Competencies (DMAS P201a) to be met.

Behavioral supports in ISP or behavioral plan require Behavioral Supports Competencies (DMAS P240a).

Advanced competency checklists are available at: https://partnership.vcu.edu/DSP_orientation/Competencies-Assurances-Tests.html

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Checklists must be initiated by DBHDS-licensed providers and DSPs, with DSPs confirmed proficient within 180 days of hire or support needs update, limited to relevant needs. Regulations require providers admit only individuals whose needs match service descriptions, availability, and staffing levels (12VAC35-105-580[/CITATION)). These competencies enhance consistency in support.

Compliance, Data, and Provider Remediation

DMAS QMR reviews provider compliance with DSP and Supervisor training. Lack of documentation results in citations for waiver non-compliance. Providers must submit corrective action plans to address deficiencies; failure to comply may lead to suspension or revocation of DMAS agreement or license.

DBHDS and DMAS collect data on compliance and remediation, part of Virginia’s overall waiver compliance approach approved by CMS.

DD Waiver Quality Assurance measures tracked for compliance include:

Number and percent of staff meeting orientation training requirements.

Number and percent of DSPs meeting competency training requirements.

Completed at Level 1

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Through these measures DBHDS and DMAS report to CMS the number of providers who meet and do not meet provider orientation training requirements. This is one means of determining Virginia’s success with operating the Building Independence, Family & Individual Supports, and Community Living Waivers.

Portability

DSPs transferring employment between agencies with documentation of completed training and passed 2016 Orientation Manual Test are not retrained; new agency discusses policies. Competencies must be confirmed within 180 days of hire and annually.

Questions can be directed to your Community Resource Consultant.

Contact list and documents are online at: http://www.dbhds.virginia.gov/developmental-services/provider-development.

Documentation Requirements Overview

DBHDS, LIC19, August 2020 1

DBHDS Office of Licensing Guidance on Corrective Action Plans (CAPs)

Effective: August 22, 2020

Purpose: This document provides guidance to DBHDS licensed providers on how to develop and implement an acceptable corrective action plan (CAP).

Regulations addressed: Note all regulatory language is formatted in italics while guidance language is in plain text located within boxes under the label “guidance.” 12VAC35-105-20. Definitions 12VAC35-105-170. Corrective Action Plan

Settlement Agreement indicators addressed:

V.C.4.8

Guidance:

12VAC35-105-20. Definitions.

The following definitions are relevant to this guidance document: "Corrective action plan" means the provider's pledged corrective action in response to cited areas of noncompliance documented by the regulatory authority. “Systemic deficiency” means violations of regulations documented by the department that demonstrate multiple or repeat defects in the operation of one or more services.

Guidance:

The development, implementation, and monitoring of CAPs are important components of a provider’s overall quality improvement process. Adequate CAPs address identified deficiencies on both an individual and systemic level.

12VAC35-105-170. Corrective action plan.

A. If there is noncompliance with any applicable regulation during an initial or ongoing review, inspection, or investigation, the department shall issue a licensing report describing the noncompliance and requesting the provider to submit a corrective action plan for each violation cited.

DBHDS, LIC19, August 2020 2 B. The provider shall submit to the department a written corrective action plan for each violation cited.

C. The corrective action plan shall include a:

1. Detailed description of the corrective actions to be taken that will minimize the possibility that the violation will occur again and correct any systemic deficiencies;
2. Date of completion for each corrective action; and
3. Signature of the person responsible for oversight of the implementation of the pledged corrective action.

Guidance:

Develop a CAP: CAPs must include a detailed description of planned corrective actions that are targeted to the mitigation or prevention of the recurrence of the regulatory violation that the CAP is intended to address, and must be sufficiently detailed to inform the Office of Licensing of the planned action steps that will be taken to fulfill the goals of the CAP. Planned actions must be verifiable, with mechanisms for verifying the completion of the planned actions incorporated into the provider’s ongoing quality improvement activities, pursuant to 12VAC35-105-620. If the provider’s pledged corrective action plan includes a one-time, permanent fix such as amending language within a form template, the provider will only need to verify completion of the planned activity once as part of its quality improvement activities.

When developing an acceptable CAP, the provider should review the citation received by the department to identify the problems that led to the issuance of the citation, including a determination as to whether or not the problem is systemic and occurring across different services, locations, or staff. Providers are required to conduct a root cause analysis (RCA) on all Level II and Level III serious incidents that occurred within the provision of the provider’s services or on the provider’s property. Therefore, if the citation was issued as the result of a serious incident, the RCA will assist the provider in identifying practices or underlying conditions that may have led to the occurrence of the serious incident. Additional assistance related to RCAs can be found within the department’s “Guidance for Serious Incident Reporting.”

Providers may also become aware of remedies to systemic issues through the following processes: conducting quarterly reviews of all serious incidents, including Level I serious incidents, pursuant to 12VAC35-105-160.C.; annual and as needed risk assessments pursuant to 12VAC35-105-520.C.; and the use of standard quality improvement tools as part of the established quality improvement program pursuant to 12VAC35-105-620.B.

Providers should consider the following steps when writing a CAP:

1. Address all problems documented in each violation by: a. Identifying the root cause(s) of the violation; b. Developing a systemic plan of action, if applicable, to address each problem, which may require updating policies, procedures, and forms, or conducting any needed training or retraining for staff, or other steps that could alleviate the problem and minimize the possibility that the violation will occur again; and c. Indicating the frequency for monitoring the plan, including how it will be monitored (Ex: monthly audits, weekly chart reviews, quarterly checklist).

DBHDS, LIC19, August 2020 3

1. Identify the staff position(s) responsible for monitoring implementation of the approved

CAP.

1. Include a date of completion for each corrective action. Providers should ensure that completion dates for planned activities are realistic, and that the individual(s) responsible for oversight of the CAP monitor and verify the completion of the planned activities.

Providers will need to submit evidence of compliance with their corrective action plans by their pledged completion date for any violations of 12VAC35-105-160.E. or 12VAC35-105-520, or any violations that pose a threat to the health and safety of individuals served (“Health and Safety CAPS”).

If a CAP is not accepted in whole or in part, it will be returned to the provider within 15 business days, with clearly stated comments and questions that indicate the specialist’s concerns.

If a CAP is returned to the provider a second time for failure to meet all requirements within 12VAC35-105-170.C., the licensing specialist will offer to have a phone call with the provider to provide technical assistance related to the criteria needed to create an acceptable CAP.

If a CAP is returned to the provider a third time for failure to meet all requirements within 12VAC35-105-170.C., the CAP will be returned and the CAP dispute process will be initiated automatically as outlined in 12VAC35-105-170.F.

Example for Creating a CAP:

After an unannounced inspection, Provider A receives a licensing report on August 1st that includes the second citation for late reporting of a serious incident within a one-year period.

1. Address all problems documented in each violation by: a. Identifying the root cause(s) of the violation.

As this is Provider A’s second citation for the same regulatory violation within one year, Provider A conducts an analysis in accordance with the written quality improvement program, to determine the root cause of these repeat violations. The analysis reveals that two different staff members failed to report the serious incidents within 24 hours of discovery. Both staff members completed serious incident reporting training less than 10 months ago and one was recently promoted to a supervisor position with additional responsibilities related to serious incident reporting. Despite this training, and analysis of the reasons for not reporting indicated that staff had not fully understood the process or responsibilities for reporting. In addition, a survey of other staff responsible for incident reporting identified inconsistent understand of reporting policy and procedure.

b. Developing a systemic plan of action to address each problem, which may require updating policies, procedures, and forms; or conducting any needed training or retraining for staff; or other steps that could alleviate the problem and minimize the possibility that the violation will occur again.

DBHDS, LIC19, August 2020 4 As part of the CAP, Provider A decides to amend the agency-wide training policy to include a test that requires a 90% passing score, and amend the new supervisor training to include review of the incident reporting requirements. The training policy is revised to state that all employees will be trained on the serious incident reporting requirements and must pass a test with a score of 90% or higher within the first 30 days of employment and prior to working alone with individuals.

Provider A recognizes that it is important to test staff understanding of the training and expectations related to incident reporting. Provider A also understands that it is important that supervisors receive additional training to enable them to monitor staff compliance with the serious incident reporting requirements. This corrective action will address the issue on both an individual and systemic level versus simply choosing to retrain the two employees who failed to report the incidents within the required timeframe.

c. Indicating the frequency for monitoring the plan to include how it will be monitored (Example: monthly audits, weekly chart reviews, quarterly checklist).

Provider A includes within the CAP that the training manager will: (i) verify all current staff have passed the serious incident report training within 30 days of hire, and (ii) document the review within a written document, to be stored with the provider’s training policy.

1. Identify the position responsible for monitoring implementation of the approved CAP.

Provider A identifies the training manager position as the position responsible for monitoring implementation of the approved CAP. In this instance, the training manager will be responsible for updating the provider’s training policy and responsible for ensuring copies of the passing test scores are included in each employee’s file. In addition, the training manager will ensure employees receive both initial and retraining on serious incident reporting on the dates outlined within the revised training policy.

1. Include a date of completion for each corrective action. Providers should ensure that completion dates for planned activities are realistic, and the staff person(s) responsible for oversight of the CAP must monitor and verify the completion of the planned activities.

Providers will need to submit evidence of compliance with their corrective action plans by their pledged completion dates for any violations of 12VAC35-105-160.E. or 12VAC35-105-520; or any violations which pose a threat to the health and safety of individuals served.

Provider A decides the corrective action plan must be completed by September 1st.

Provider A is confident that this date is a realistic amount of time to amend the training policy and retrain employees.

Provider A’s training manager (as identified in #2 above) will monitor implementation and effectiveness of approved corrective actions as part of the established quality improvement program required by 12VAC35-105-620 (see below). This might include developing a quality assurance process to monitor and track the timeliness of all serious incident reporting to ensure that the corrective actions are having the intended affect.

DBHDS, LIC19, August 2020 5 D. The provider shall submit a corrective action plan to the department within 15 business days of the issuance of the licensing report. One extension may be granted by the department when requested prior to the due date, but extensions shall not exceed an additional 10 business days.

An immediate corrective action plan shall be required if the department determines that the violations pose a danger to individuals receiving the service.

Guidance:

Extensions to the 15 business day timeline for submitting a CAP may be granted to a provider only if requested by the provider PRIOR to the due date, and only for one additional period of up to 10 business days. The new due date for the CAP will be up to 10 days from the date the CAP was due, and not up to 10 days from the date the extension was requested.

If a licensing specialist determines during an inspection or investigation that there is an immediate and substantial threat to the health, safety, or welfare of the individuals receiving services, the licensing specialist will immediately address the concerns with the provider and will request that the provider develop and commit to a CAP during the onsite inspection. If the provider fails to suggest a CAP during the inspection, the specialist will suggest one.

E. Upon receipt of the corrective action plan, the department shall review the plan and determine whether the plan is approved or not approved. The provider has an additional 10 business days to submit a revised corrective action plan after receiving a notice that the department has not approved the revised plan. If the submitted revised corrective action plan is not approved, the provider shall follow the dispute resolution process identified in this section.

Guidance:

The Office of Licensing will respond to CAPs within 15 business days of receipt of the provider’s CAP.

CAPs will be approved if they include: (1) detailed and verifiable corrective actions targeted to remedying and preventing the recurrence of identified regulatory violations; (2) realistic planned completion dates for each of the planned actions; and (3) the signature of the identified responsible person for monitoring the implementation of the planned actions. In addition, the provider’s CAP must address the systemic plan of action to address each problem, as applicable (please refer to the example above).

F. When the provider disagrees with a citation of a violation or the disapproval of a revised corrective action plan, the provider shall discuss this disagreement with the licensing specialist initially. If the disagreement is not resolved, the provider may ask for a meeting with the licensing specialist's supervisor, in consultation with the director of licensing, to challenge a finding of noncompliance. The determination of the director is final.

DBHDS, LIC19, August 2020 6 Guidance:

CAP Dispute Resolution Process:

• Providers should promptly communicate disagreement with a citation directly to the specialist who issued the citation (licensing specialist, IMU specialist, or investigator). If a provider does not communicate his disagreement with the specialist before the CAP is due, a citation will be issued for not submitting the CAP on time. Per the regulation, the provider must reach out to their licensing specialist to discuss the disagreement prior to reaching out to the licensing specialist’s supervisor.

• If a provider disagrees with a citation, and is not able to resolve the disagreement with their specialist, the CAP dispute resolution process will be initiated.

• The CAP dispute resolution may be initiated by the provider or the specialist if the two parties are not able to come to an agreement related to the issued citation(s).

• The purpose of the CAP dispute resolution process meeting is fact-finding and will include open discussion of the dispute issues to promote understanding of the provider’s position on citations issued. Accordingly, the provider and specialist are encouraged to present information relevant to the grievance at this meeting.

• While the parties may question one another regarding disputed facts and issues, the meeting should not be adversarial or treated as a hearing.

• The specialist’s supervisor is charged with presiding over the meeting and will serve as a neutral party to the dispute.

• No decisions will be made at the time of this meeting and the information will be gathered from the meeting and discussed with the Office of Licensing Assistant Director and Director to make a final decision.

• After the CAP dispute meeting, the specialist’s supervisor will make a recommendation to the Office of Licensing Director or the director’s designee.

• The Office of Licensing Director or designee will issue a final decision in writing regarding the citation within 10 business days from the CAP dispute meeting. The Office of Licensing Director’s decision is final.

• If the citation is upheld, the provider will have 10 business days to submit the CAP.

• If the citation is not upheld, the Office of Licensing will remove the violation from the licensing report.

• Nothing in this procedure will prevent the Office of Licensing from requiring immediate corrective action when the violation presents a threat to the health, safety, or welfare of individuals served.

DBHDS, LIC19, August 2020 7 G. The provider shall implement their written corrective action plan for each violation cited by the date of completion identified in the plan.

Guidance:

Implement the Plan: For serious injuries and deaths that result from substantiated abuse, neglect, or health and safety violations (“Health and Safety CAPs”), the Office of Licensing verifies that CAPs are implemented within 30 business days of the date the corrective action plan was approved.

Failure to implement a written CAP will result in a licensing report citing 12VAC35-105-170.G.

H. The provider shall monitor implementation and effectiveness of approved corrective actions as part of its quality improvement program required by 12VAC35-105-620. If the provider determines that an approved corrective action was fully implemented, but did not prevent the recurrence of a regulatory violation or correct any systemic deficiencies, the provider shall:

1. Continue implementing the corrective action plan and put into place additional measures to prevent the recurrence of the cited violation and address identified systemic deficiencies; or
2. Submit a revised corrective action plan to the department for approval.

Guidance:

Monitor CAP: In order to demonstrate compliance with this regulation, each provider must show proof of monitoring all CAPs for implementation and effectiveness.

If after completion of the planned activities the provider determines that the issue that led to a citation occurred again, then the provider shall implement the provider’s own policies and procedures for updating the provider’s quality improvement plan, if applicable, or submitting revised corrective action plans, pursuant to 12VAC35-105-620.D. This may include determining whether or not the CAP was implemented as intended.

1. If the CAP was not fully implemented as intended, the provider should evaluate and address any barriers to implementation.

1. If the CAP was fully implemented, the provider should assess the reasons that the issue recurred and make a determination as to whether changes to the corrective action plan are necessary.

• While prevention of a second regulatory violation may not always be possible, prevention is the goal. If a second regulatory violation occurs, the provider should always analyze whether the current CAP is the most effective means of preventing reoccurrence or if additional steps could be taken.
• A provider may determine after review that the recurrence of a regulatory violation was not due to the insufficiency of the implemented corrective actions, and that the planned corrective actions remain the most effective means of preventing or substantially mitigating future recurrences. If this is the case, then the provider should clearly document through the quality improvement program the basis for this conclusion and continue implementing the planned corrective actions without additional measures.

DBHDS, LIC19, August 2020 8

• If the provider determines that revisions to the CAP are necessary, those revisions should be submitted to the licensing specialist for review and approval. The provider should document through the quality improvement program, if applicable, when it is determined that an issue has been corrected and monitoring may be discontinued.

Example Continued:

Provider A successfully implements the CAP by revising the training policy and ensuring all employees passed the test with a score of 90% or higher by the completion date outlined in the CAP. However, on January 1st, the provider self-identifies the failure to report a serious incident in a timely manner through the quality assurance process implemented as a result of the initial corrective action. The provider’s quality assurance process involved tracking the timeliness of reporting each serious on a quarterly basis. A review of the data identified three instances (out of 25 serious incidents) when reports were not made within 24 hours.

Provider A determines that the approved CAP was fully implemented. However, it did not correct the identified systemic deficiency. Provider A has two options: 1) to continue implementing the CAP and put into place additional measures to prevent the recurrence of the cited violation and address identified systemic deficiencies; or 2) submit a revised CAP to the department for approval. If the provider determined that the approved corrective actions are the most effective means of addressing the issue, then this rationale should be documented through the quality improvement program and the provider may continue implementing the approved corrective actions.

In accordance with the provider’s quality improvement policy, Provider A conducts an analysis into why the CAP was not effective. Provider A’s analysis determines that while the staff pass a test, applying the knowledge to real life situations is more difficult. As a result, Provider A determines that the CAP will continue to be implemented, but also will make sure to talk through real life scenarios and examples during each staff meeting. Provider A also implements a motto with all staff, “When in doubt, talk it out,” to encourage staff to call a supervisor if they have any questions about whether an occurrence may be considered a Level II or Level III serious incident.

After one year, the provider determines through quarterly monitoring that 100% of serious incidents were reported within 24 hours. Based on attaining the objectives of the CAP, the provider determines that this issue was successfully addressed and closes it as a quality improvement goal, consistent with the policies and procedures.

DBHDS, LIC19, August 2020 1

DBHDS Office of Licensing Guidance on Corrective Action Plans (CAPs)

Effective: August 22, 2020

Purpose: This document guides DBHDS licensed providers on developing and implementing acceptable corrective action plans (CAP).

Regulations addressed: Italicized regulatory language; guidance in plain text within boxes labeled “guidance.” 12VAC35-105-20. Definitions 12VAC35-105-170. Corrective Action Plan

Settlement Agreement indicators addressed:

V.C.4.8

Guidance:

12VAC35-105-20. Definitions.

Definitions: "Corrective action plan" is the provider's pledged response to cited noncompliance; “Systemic deficiency” indicates violations showing multiple or repeat defects in services.

Guidance:

Development, implementation, and monitoring of CAPs are key to quality improvement, addressing deficiencies individually and systemically.

12VAC35-105-170. Corrective action plan.

A. During reviews, inspections, or investigations, if noncompliance occurs, the department will issue a report detailing violations and requesting a corrective action plan for each.

DBHDS, LIC19, August 2020 2 B. The provider must submit a written CAP for each cited violation.

C. The corrective action plan shall include a:

1. Detailed description of corrective actions to minimize recurrence and address systemic deficiencies;
2. Completion date for each corrective action;
3. Signature of the person overseeing implementation of corrective actions.

Guidance:

Develop a CAP: CAPs must include a detailed description of planned corrective actions that are targeted to the mitigation or prevention of the recurrence of the regulatory violation that the CAP is intended to address, and must be sufficiently detailed to inform the Office of Licensing of the planned action steps that will be taken to fulfill the goals of the CAP. Planned actions must be verifiable, with mechanisms for verifying the completion of the planned actions incorporated into the provider’s ongoing quality improvement activities, pursuant to 12VAC35-105-620. If the provider’s pledged corrective action plan includes a one-time, permanent fix such as amending language within a form template, the provider will only need to verify completion of the planned activity once as part of its quality improvement activities.

When developing a CAP, review the citation to identify issues, determine if systemic, and conduct root cause analysis (RCA) on all Level II/III serious incidents to identify underlying causes. Additional RCA guidance is available.

Providers can identify systemic remedies through quarterly reviews of all serious incidents, annual risk assessments, and standard quality improvement tools, per citations.

Providers should consider the following steps when writing a CAP:

1. Address all violation problems by: a. Identifying root causes; b. Developing a systemic plan, including updates, training, or other steps; c. Specifying monitoring frequency and methods.

DBHDS, LIC19, August 2020 3

1. Identify staff responsible for monitoring implementation of the approved

CAP.

1. Include completion dates for each corrective action, ensuring they are realistic and that responsible individuals monitor and verify completion.

Providers must submit evidence of CAP compliance by the pledged date for violations of 12VAC35-105-160.E., 12VAC35-105-520, or any health and safety threats.

If a CAP is partially or wholly rejected, it will be returned within 15 business days with comments and questions.

If returned a second time for non-compliance, the licensing specialist will offer a phone call for technical assistance on CAP criteria.

After a third return for non-compliance, the CAP will be returned and the dispute process initiated per 12VAC35-105-170.F.

Example for Creating a CAP:

Following an unannounced inspection, Provider A received a licensing report on August 1st citing late reporting of a serious incident for the second time in a year.

1. Address all violation problems by: a. Identifying root causes.

As this is Provider A’s second citation for the same regulatory violation within one year, Provider A conducts an analysis in accordance with the written quality improvement program, to determine the root cause of these repeat violations. The analysis reveals that two different staff members failed to report the serious incidents within 24 hours of discovery. Both staff members completed serious incident reporting training less than 10 months ago and one was recently promoted to a supervisor position with additional responsibilities related to serious incident reporting. Despite this training, and analysis of the reasons for not reporting indicated that staff had not fully understood the process or responsibilities for reporting. In addition, a survey of other staff responsible for incident reporting identified inconsistent understand of reporting policy and procedure.

b. Develop a systemic plan addressing each issue, including policy updates, training, or other steps to prevent recurrence.

DBHDS, LIC19, August 2020 4 As part of the CAP, Provider A decides to amend the agency-wide training policy to include a test that requires a 90% passing score, and amend the new supervisor training to include review of the incident reporting requirements. The training policy is revised to state that all employees will be trained on the serious incident reporting requirements and must pass a test with a score of 90% or higher within the first 30 days of employment and prior to working alone with individuals.

Provider A will test staff understanding, enhance supervisor training, and address issues systemically, not just retrain the two employees who failed to report timely.

c. Specify monitoring frequency and methods (e.g., monthly audits, weekly reviews, quarterly checklists).

Provider A's CAP states the training manager will verify all staff pass incident report training within 30 days and document reviews with training policy.

1. Identify the position responsible for monitoring the CAP implementation.

The training manager will monitor CAP implementation, update training policies, ensure test scores are in employee files, and oversee initial and retraining per policy.

1. Include completion dates for each corrective action; responsible staff must monitor and verify completion, ensuring dates are realistic.

Providers must submit evidence of CAP compliance by the pledged date for violations of 12VAC35-105-160.E., 12VAC35-105-520, or any health and safety threats.

Provider A sets CAP completion date as September 1st.

Provider A believes this date allows sufficient time to amend policies and retrain employees.

Provider A’s training manager will monitor implementation and effectiveness of approved corrective actions as part of the quality improvement program required by 12VAC35-105-620, including developing a process to track serious incident reporting timeliness.

DBHDS, LIC19, August 2020 5 D. The provider shall submit a corrective action plan to the department within 15 business days of the issuance of the licensing report. One extension may be granted by the department when requested prior to the due date, but extensions shall not exceed an additional 10 business days.

An immediate corrective action plan is required if violations threaten individuals' safety.

Guidance:

Extensions to the 15-day deadline require prior request and are limited to one extension of up to 10 days; the new due date is up to 10 days after the original deadline.

If a licensing specialist finds an immediate threat during inspection, they will address concerns and request a CAP; if the provider does not suggest one, the specialist will.

Upon receiving the CAP, the department will review and approve or disapprove. The provider has 10 days to submit a revised plan; if still disapproved, follow dispute resolution.

Guidance:

The Office of Licensing will respond to CAPs within 15 business days of receipt.

CAPs are approved if they include: (1) detailed, verifiable corrective actions; (2) realistic completion dates; (3) responsible person’s signature; and (4) systemic action plan, as applicable.

If the provider disagrees with a violation citation or disapproval, they must first discuss with the licensing specialist; unresolved issues may be escalated to the supervisor and licensing director, whose decision is final.

DBHDS, LIC19, August 2020 6 Guidance:

CAP Dispute Resolution Process:

• Providers must promptly communicate citation disagreements to the issuing specialist before CAP deadline; failure results in citation for late submission; discuss with licensing specialist first.

• If disagreement persists after discussion, initiate CAP dispute resolution process.

• The CAP dispute resolution may be initiated by the provider or the specialist if the two parties are not able to come to an agreement related to the issued citation(s).

• Dispute resolution is fact-finding with open discussion to understand provider’s position; relevant information may be presented.

• Parties may question facts but the meeting is not adversarial or a hearing.

• Specialist’s supervisor presides as a neutral party.

• No decisions at the meeting; information will be reviewed with licensing leadership for final decision.

• Supervisor will recommend to Licensing Director or designee after the dispute meeting.

• Final written decision issued within 10 business days; decision is final.

• Uphold: provider has 10 days to submit CAP.

• Not upheld: violation removed from report.

• This procedure does not prevent immediate action if violation threatens health, safety, or welfare.

DBHDS, LIC19, August 2020 7 G. The provider shall implement their written corrective action plan for each violation cited by the date of completion identified in the plan.

Guidance:

Implement the Plan: For serious injuries and deaths that result from substantiated abuse, neglect, or health and safety violations (“Health and Safety CAPs”), the Office of Licensing verifies that CAPs are implemented within 30 business days of the date the corrective action plan was approved.

Failure to implement a written CAP will result in a licensing report citing 12VAC35-105-170.G.

The provider shall monitor implementation and effectiveness of approved corrective actions as part of the quality improvement program required by 12VAC35-105-620.. If fully implemented but ineffective, the provider shall:

1. Continue CAP implementation and add measures to prevent recurrence and systemic deficiencies;
2. Submit revised CAP for approval.

Guidance:

Monitor CAP: In order to demonstrate compliance with this regulation, each provider must show proof of monitoring all CAPs for implementation and effectiveness.

If the issue recurs after planned activities, the provider shall update its quality improvement plan or submit revised CAPs per 12VAC35-105-620., including verifying CAP implementation as intended.

1. If CAP not fully implemented, evaluate and address barriers.

1. If fully implemented, assess recurrence reasons and determine if CAP changes are needed.

• Prevention is the goal; if a second violation occurs, analyze CAP effectiveness and consider additional steps.
• If recurrence isn't due to CAP insufficiency, document this via QI and continue current corrective actions.

DBHDS, LIC19, August 2020 8

• If revisions are needed, submit to licensing for review; document issue correction and monitoring discontinuation via QI.

Example Continued:

Provider A implements the CAP by revising training policies and ensuring all employees score 90%+. However, on Jan 1, it self-identified failure to report a serious incident timely via QA process, which tracked quarterly. Data showed 3 of 25 incidents were late.

Provider A finds the CAP fully implemented but systemic deficiency persists. It can continue with additional measures or submit a revised CAP for approval, documenting rationale via QI.

Provider A analyzes why the CAP was ineffective, finding staff pass tests but struggle with real-life application. It will continue CAP, adding scenario discussions and a motto, “When in doubt, talk it out,” to encourage staff to consult supervisors on incidents.

After one year, quarterly monitoring shows 100% of serious incidents reported within 24 hours. The provider concludes the issue is addressed and closes it as a QI goal.

REVISED.DBHDS, LIC17, November 2020 1

DBHDS Office of Licensing Guidance for Serious Incident Reporting

Effective: November 28, 2020

Purpose: This document contains guidance to providers regarding the definition of “serious incident” and the corresponding reporting requirements adopted to address compliance with the US Department of Justice's Settlement Agreement with Virginia within the Rules and Regulations for Licensing Providers by the Department of Behavioral Health and Developmental Services [12VAC35-105] (“Licensing Regulations”). For additional information related to the department expectations for serious incident reporting please visit the department’s August 22, 2020, Incident Reporting Memo.

Regulations addressed: Note all regulatory language is formatted in italics while guidance language is in plain text located within boxes under the label “guidance.” 12VAC35-105-20. Definitions. 12VAC35-105-160. Reviews by the department; requests for information; required reporting.

12VAC35-105-20. Definitions. "Serious incident" means any event or circumstance that causes or could cause harm to the health, safety, or well-being of an individual. The term "serious incident" includes death and serious injury. "Level I serious incident" means a serious incident that occurs or originates during the provision of a service or on the premises of the provider and does not meet the definition of a Level II or Level III serious incident. Level I serious incidents do not result in significant harm to individuals, but may include events that result in minor injuries that do not require medical attention or events that have the potential to cause serious injury, even when no injury occurs.

Guidance:

Providers are not required to report Level I serious incidents via DBHDS’ web-based reporting application (CHRIS) to the Office of Licensing.

Level I serious incidents, by definition, occur or originate during the provision of services or on the premises of the provider. “[D]uring the provision of a service” means that the incident occurs when the provider is actively providing a service to the individual. o For example, if an individual reports to his case manager that the individual fell off of his bicycle at the group home and sustained minor injuries, the case manager is not required to collect, maintain, and review this information as part of the quality improvement program, although this information may be pertinent to the case manager’s responsibilities under 12VAC35-105-1245. The DBHDS-licensed group home provider, however, is required to collect, maintain, and review this information as part of its quality improvement program (discussed further below).

REVISED.DBHDS, LIC17, November 2020 2

"Level II serious incident" means a serious incident that occurs or originates during the provision of a service or on the premises of the provider that results in a significant harm or threat to the health and safety of an individual that does not meet the definition of a Level III serious incident.

"Level II serious incident" includes a significant harm or threat to the health or safety of others caused by an individual.

Guidance:

Like Level I serious incidents, Level II serious incidents, by definition, occur or originate during the provision of services or on a provider’s premises, where “during the provision of services” means that the incident occurs when the provider is actively providing a service to the individual. If the provider is notified of a Level II serious incident that occurred or originated when the provider was not actively providing a service, then the provider is not required to report the incident. o For example, an individual receiving case management services reports to their case manager that last week they went to the emergency room because they were in a car accident. The case manager is not required to report the incident.

Providers licensed to provide a “residential service” as defined by 12VAC35-105-20 provide 24-hour support to individuals. However, if an individual receiving residential services experiences a Level II serious incident while actively receiving services from another licensed provider, the residential service provider is not required to report the incident if the provider attempts to verify that the other provider reported the incident. Once a residential provider becomes aware that an individual experienced a Level II serious incident during the provision of another provider’s services, the residential provider should reach out directly to the other provider to attempt to verify that the other provider reported the incident. The residential provider should select a consistent manner to document any attempts to verify the submission of an incident report by another provider, as well as the other provider’s response.

Verification may occur through phone conversations, face-to-face interactions, e-mails, or fax.

A simple confirmation from the other provider that they submitted the report is sufficient; the residential provider is not required to receive a copy of the incident report. If the residential provider cannot receive confirmation from the other provider that a serious incident report was submitted, then the residential provider may submit a complaint to the Office of Licensing at olcomplaints@dbhds.virginia.gov. o For example, if an individual who receives group home services sustains a serious injury at a day support program, the group home provider is not required to report the serious injury as long as the group home provider reaches out to the day support provider to verify that the day support provider reported the incident. The group home provider should document all attempts to reach out to the day support provider and the response received. o However, if an individual receiving services from a residential service provider sustains a serious injury during an independent trip to the grocery store, the residential service provider must report the serious injury as a Level II serious incident.

In addition, if an individual receiving services is temporarily away from a provider’s services for a visit or trip with family, and the individual experiences a Level II serious incident, the incident does not need to be reported to the Office of Licensing.

REVISED.DBHDS, LIC17, November 2020 3

o For example, an individual who receives group home services has a choking incident which requires direct physical intervention while on a family trip to the beach. When the individual returns, their parent informs the provider of the incident. The provider does not need to report the choking incident requiring physical intervention as a Level II serious incident. However, the provider should internally document the report made by the family and based on the specific details surrounding the incident, the provider may need to evaluate individual supports to determine if they are still appropriate.

“Level II serious incident” also includes a significant harm or threat to the health or safety of others caused by an individual. o Peer to peer incidents that result in significant harm or threat to the health or safety of an individual by an another individual should be reported to the Office of Licensing as two separate Level II serious incidents in the CHRIS reporting system.
For example, if Individual #1 punches Individual #2 and Individual #2 sustains a broken nose, this Level II serious incident should be reported into CHRIS as a Level II serious incident for Individual #1 because that person caused significant harm to another individual. This incident should also be reported as a Level II serious incident for Individual #2 because that person sustained a serious injury.

The provider is also required to report the incident for Individual #2 to the Office of Human Rights and investigate as required by Regulations to Assure the Rights of Individuals Receiving Services from Providers Licensed, Funded, or Operated by the Department of Behavioral Health and Developmental Services [12VAC35-115-50] (“Human Rights Regulations”). o Peer to peer incidents that do not result in significant harm or threat to the health of the safety of an individual by another individual do not need to be reported to the Office of Licensing as a Level II serious incident. "Level II serious incidents" include:

Guidance:

Please note that per Code of Virginia § 1-218 the term “includes” means “includes, but not limited to.” Therefore, Level II serious incidents are not limited to the incidents enumerated below.

1. A serious injury;

Guidance:

“Serious injury” means “any injury resulting in bodily hurt, damage, harm, or loss that requires medical attention by a licensed physician, doctor of osteopathic medicine, physician assistant, or nurse practitioner.”

1. An individual who is or was missing;

Guidance:

“Missing” is defined in 12VAC35-105-20 as “a circumstance in which an individual is not physically present when and where he should be and his absence cannot be accounted for or explained by his supervision needs or pattern of behavior.”

REVISED.DBHDS, LIC17, November 2020 4

Providers are not expected to report missed appointments. o For example, if an individual admitted for outpatient or case management services misses an appointment, the person is not considered missing.

1. An emergency room visit;

Guidance:

Emergency room visits by an individual receiving services, other than licensed emergency services, shall be reported as Level II serious incidents if they occur within the provision of the provider’s services or on their premises.

If the provider calls first responders due to an emergency, and an emergency medical technician (EMT) recommends an ER visit but the individual declines to go, this does not need to be reported as there was no “emergency room visit” as listed within the regulations.

Please note that if there was another Level II serious incident which led to the call for first responders, then that should be reported as a Level II serious incident.

o For example, an individual experiences a choking incident, which requires direct physical intervention, and 911 is dialed. By the time the EMTs arrive, provider staff were able to successfully clear the individual’s airway. The EMTs suggest that the individual should still be transported to the emergency room for an evaluation, but the individual refuses to go. The provider does not need to report this as an emergency room visit as the individual refused to go to the emergency room. However, the incident should still be reported as a Level II serious incident as it was a choking incident which required direct physical intervention.

If an individual is taken to the emergency room and later refuses care while at the emergency room, this should still be reported as a Level II serious incident as an emergency room visit did occur.

1. An unplanned psychiatric or unplanned medical hospital admission of an individual receiving services other than licensed emergency services, except that a psychiatric admission in accordance with the individual's Wellness Recovery Action Plan (WRAP) shall not constitute an unplanned admission for the purposes of this Chapter;

Guidance:

If an individual is admitted to the hospital for psychiatric services, and the individual’s admission is in accordance with the individual’s Wellness Recovery Action Plan (WRAP), then the admission is not an unplanned admission and does not need to be reported.

In addition, if an individual is only receiving licensed emergency services and no other licensed service at the time the individual experiences an unplanned psychiatric admission, the emergency service provider is not required to report the admission. o “Emergency service” is defined as “unscheduled and sometimes scheduled crisis intervention, stabilization, and referral assistance provided over the telephone or face-to-face, if indicated, available 24 hours a day and seven days per week. Emergency services also may include walk-ins, home visits, jail interventions, and preadmission screening activities associated with the judicial process.”

REVISED.DBHDS, LIC17, November 2020 5

If an individual is receiving services from a provider other than an emergency service provider (e.g., residential service, day support, mental health community support), and the individual experiences an unplanned psychiatric admission while the provider is actively providing a service to the individual, the provider is required to report the unplanned admission. o For example:
An individual living in a group home experiences a psychiatric crisis while in the group home that leads to the issuance of a TDO and an unplanned hospital admission. The group home provider would be required to report the incident.
During a treatment session, an outpatient service provider is concerned about an individual’s suicidal intent; the provider arranges to have the individual evaluated and then the individual is admitted to the hospital. The outpatient provider would report the incident.
If an individual who receives outpatient services experiences suicidal thoughts at a time when the individual is not in a therapy session with the outpatient service provider and the individual contacts emergency services and ultimately experiences an unplanned psychiatric admission, then neither the outpatient service provider nor the emergency service provider would be required to report the incident.

If an individual is receiving case management services at the time of an unplanned psychiatric or unplanned medical hospital admission, the case manager is only required to report the incident if the admission occurred while the case manager was actively providing case management service to the individual.

If an individual is admitted to a hospital due to an unplanned medical issue (e.g., appendicitis, a fractured bone, a burn, the flu, sepsis, etc.) that occurred while the individual was receiving services, then the provider that was providing the service would be required to report the incident. But, if the incident requiring admission did not occur during the provision of services, then it would not need to be reported.

1. Choking incidents that require direct physical intervention by another person;

Guidance:

If an individual experiences a choking incident that requires physical aid by another person, such as abdominal thrusts (Heimlich maneuver); back blows; clearing the airway; or CPR; then the provider must report the incident.

If an individual chokes on food but is able to cough up the food without the physical aid of another person, then the provider is not required to report the incident as a Level II serious incident. However, the choking incident should be recorded by the provider as a Level I serious incident, because choking is an event that has the potential to cause serious injury.

1. Ingestion of any hazardous material;

Guidance:

If an individual drinks, swallows, or absorbs a material that causes significant harm to the individual or is a threat to the individual’s health and safety, the provider must report this as a Level II serious incident.

REVISED.DBHDS, LIC17, November 2020 6

The DBHDS safety alert “Hazards of Household Products” provides additional guidance about hazardous materials.

7. A diagnosis of:

a. A decubitus ulcer or an increase in severity of level of previously diagnosed decubitus ulcer;

Guidance:

A diagnosis of decubitus ulcer or an increase in level of severity of a previously diagnosed decubitus ulcer must be reported as a Level II serious incident once the provider has sought and obtained a diagnosis from a medical professional.

It is recommended that providers review the DBHDS safety alert for “pressure ulcers” for the definition and description of levels regarding decubitus ulcer. b. A bowel obstruction; or

Guidance:

A diagnosis of a bowel obstruction must be reported as a Level II serious incident once the provider has sought and obtained a diagnosis from a medical professional.

It is recommended providers review the DBHDS safety alert for “constipation.” c. Aspiration pneumonia.

Guidance:

A diagnosis of aspiration pneumonia must be reported as a Level II serious incident once the provider has sought and obtained a diagnosis from a medical professional.

It is recommended providers review the DBHDS safety alert for “dysphagia/aspiration.”

"Level III serious incident" means a serious incident whether or not the incident occurs while in the provision of a service or on the provider’s premises and results in:

“[W]hile in the provision of a service” means that an incident occurs when the provider is actively providing a service to the individual.

Providers must report all Level III serious incidents even if the incident did not occur on the provider’s premises or while the provider was actively providing a service to the individual.

All providers that are aware of a Level III serious incident affecting an individual receiving services are required to report the incident even though it may result in duplicative reporting. 1) Any death of an individual;

Guidance:

REVISED.DBHDS, LIC17, November 2020 7

All providers, including case managers, must report the death of any individual receiving services from the provider at the time of death. o For example, if an in-home supports provider and a case manager receive notification that an individual receiving services died over the weekend, both are required to report the death. 2) A sexual assault of an individual;

Guidance:

Any sexual assault required by other applicable laws to be reported to other relevant authorities shall be reported to those authorities in accordance with the law.

The provider must report any sexual assault of an individual receiving services alleged to have resulted from any act or failure to act by the provider’s employee or other person responsible for the care of an individual in the provider’s program.

The provider must report to DBHDS any alleged sexual assault of a minor or of an adult who is determined to lack capacity pursuant to 12VAC35-115-145.

DBHDS recognizes that reporting an allegation of sexual assault could impact the therapeutic relationship of the individual with the provider; therefore, reporting should be trauma-informed and respect the therapeutic relationship.

For alleged sexual assault of an individual who is an adult with capacity: o If the alleged sexual assault occurs in the provision of a service or on the provider’s premises, the provider must report the alleged sexual assault to DBHDS. o If the alleged sexual assault does not occur in the provision of a service or on the provider’s premises, reporting of the alleged sexual assault to DBHDS is required only if the adult with capacity gives consent for the report to be made. 3) A suicide attempt by an individual admitted for services, other than licensed emergency services, that results in a hospital admission.

Guidance:

DBHDS regulation 12VAC35-105-20 defines a “suicide attempt” as “a nonfatal, self-directed, potentially injurious behavior with an intent to die as a result of the behavior regardless of whether it results in injury.”

If an individual admitted for services is admitted to the hospital as a result of self-directed behavior, and it is determined by a licensed professional that the individual intended to die as a result of the behavior, all providers are required to report this incident as a Level III serious incident regardless of whether the incident occurred within the provision of their services or on their property.

Self-injurious behavior without the intent to die that results in a hospital admission or emergency room visit does not need to be reported as a Level III serious incident by all providers. However, the incident must be reported as a Level II serious incident by a provider if the incident occurred within the provision of their services or on their property.

REVISED.DBHDS, LIC17, November 2020 8

Providers must report a suicide attempt that results in a hospital admission by an individual if the individual is already admitted to, or receiving any licensed service at the time of the attempt, whether or not the attempt occurred on the provider’s premises or while the provider was actively providing services to the individual. o For example, if an individual receiving outpatient services attempts suicide over the weekend and is admitted to the hospital, the outpatient provider must report this incident even though the individual was not within the provision of the outpatient provider’s services at the time of the incident.

If an individual is only receiving licensed emergency services, and no other licensed service at the time of the suicide attempt, the emergency services provider is not required to report the incident.

REVISED.DBHDS, LIC17, November 2020 9

12VAC35-105-160. Reviews by the department; requests for information; required reporting.

A. The provider shall permit representatives from the department to conduct reviews to:

1. Verify application information;

1. Assure compliance with this chapter; and
2. Investigate complaints.

B. The provider shall cooperate fully with inspections and investigations and shall provide all information requested by the department.

Guidance:

Representatives of DBHDS will request documentation from a provider, including documents relating to an individual’s death, to determine if the provider complied with DBHDS regulations.

Examples of Non-Compliance: o Failure to provide information or documentation requested by DBHDS to determine compliance with regulations.

C. The provider shall collect, maintain, and review at least quarterly all serious incidents, including Level I serious incidents, as part of the quality improvement program in accordance with 12VAC35-105-620 to include an analysis of trends, potential systemic issues or causes, indicated remediation, and documentation of steps taken to mitigate the potential for future incidents.

Guidance:

The reason for provider monitoring of Level I, II and III serious incidents is to minimize the risk of any future serious incidents.

Provider quality improvement plans, required by 12VAC35-105-620, must address how the provider will identify trends and systemic issues and indicate remediation and the steps taken to mitigate (reduce or alleviate) the potential for future incidents.

Example: o A provider’s quarterly review of Level I incidents identified several falls without serious injury to individuals.

1. Analysis of trends – Examples of an analysis of trends include: the provider reviews all falls, falls per individual, the environment in which the falls occurred, time of day when the falls occurred, etc., to determine any trends and look at any patterns (e.g., same individual, same location, like locations, i.e. bathrooms). Through this analysis, the provider can determine if the issue is systemic and how best to address it.

1. Potential systemic issues or causes – The provider reviews policies, procedures, or protocols related to fall prevention. For example, systemic causes could include a lack of a protocol for assessing an individual’s fall risk, an environment that increases the risk of falls (area rugs that slip or can be tripped over, furniture placement, etc.), or other causes that can affect multiple individuals.

REVISED.DBHDS, LIC17, November 2020 10

1. Indicated remediation – The provider makes recommendations to prevent a reoccurrence. Depending on the trend analysis, this remediation could be related to falls sustained by one individual or all individuals. For example, if falls occurred from a bed, the provider may mitigate future incidents by placing a fall mat near a bed to prevent serious injuries.

1. Documentation of steps taken to mitigate the potential for future incidents – The provider documents specific steps or actions taken to reduce or manage the likelihood or severity of an adverse outcome.

For additional information, please see the DBHDS Office of Licensing, Guidance for a Quality Improvement Program.

D. The provider shall collect, maintain, and report or make available to the department the following information:

1. Each allegation of abuse or neglect shall be reported to the department as provided in

12VAC35-115-230 A.

Guidance:

Providers shall report each allegation of abuse or neglect via the Human Rights side of CHRIS within 24 hours of receipt of the allegation.

[NOTE: This is not a change]

1. Level II and Level III serious incidents shall be reported using the department's web-based reporting application and by telephone or email to anyone designated by the individual to receive such notice and to the individual's authorized representative within 24 hours of discovery. Reported information shall include the information specified by the department as required in its web-based reporting application, but at least the following: the date, place, and circumstances of the serious incident. For serious injuries and deaths, the reported information shall also include the nature of the individual's injuries or circumstances of the death and any treatment received. For all other Level II and Level III serious incidents, the reported information shall also include the consequences that resulted from the serious incident. Deaths that occur in a hospital as a result of illness or injury occurring when the individual was in a licensed service shall be reported.

Guidance:

Level II and Level III serious incidents shall be reported via the Licensing side of CHRIS within 24 hours of discovery.

In addition, providers must report Level II and Level III serious incidents to an individual’s guardian or authorized representative within 24 hours of discovering the incident.

Providers must report deaths if the individual was not yet discharged from the service at the time of death.

REVISED.DBHDS, LIC17, November 2020 11

1. Instances of seclusion or restraint shall be reported to the department as provided in

12VAC35-115-230 C 4.

Guidance:

Providers must report to DBHDS via the Human Rights side of CHRIS within 24 hours any instance of seclusion or restraint that does not comply with the Human Rights Regulations or approved variances, or that results in injury to an individual. The individual’s authorized representative, if applicable, must also be notified by the provider within 24 hours.

[NOTE: This is not a change.] E. A root cause analysis shall be conducted by the provider within 30 days of discovery of Level II serious incidents and any Level III serious incidents that occur during the provision of a service or on the provider's premises.

Guidance:

“Root cause analysis” (RCA), as defined by 12VAC35-105-20, is “a method of problem solving designed to identify the underlying causes of a problem. The focus of a root cause analysis is on systems, processes, and outcomes that require change to reduce the risk of harm.”

An RCA does not focus on the people involved but focuses on systems, processes, and outcomes. The goals of an RCA are to find out what happened, why it happened, and determine if action needs to be taken. A root cause analysis as required in these regulations should include, at a minimum, documentation that the three elements below were considered to the extent that they are known, or could be known by the provider.

1. The root cause analysis shall include at least the following information: a. A detailed description of what happened;

Guidance:

Documentation of what happened should include the step-by-step sequence of events leading up to the incident and the actions taken immediately following the incident. b. An analysis of why it happened, including identification of all identifiable underlying causes of the incident that were under the control of the provider; and

Guidance:

Analysis of why an incident occurred should:

1. Compare what happened to what should have happened before, during, and after the incident.
2. Compare the actions taken before, during, and after the incident to the requirements in the provider’s policies and procedures, DBHDS licensing and other applicable regulations, accreditation standards, and applicable laws.
3. Clearly identify the underlying causes of the incident that were under the control of the provider.

REVISED.DBHDS, LIC17, November 2020 12

c. Identified solutions to mitigate its reoccurrence and future risk of harm when applicable.

Guidance:

The RCA should identify solutions, as applicable, to be taken by the provider to keep the situation from occurring again or minimize the likelihood of its reoccurrence and future risk of harm.

These solutions should be both individual-specific and systemic as indicated by the analysis of the incident. Implementation of these solutions and their effectiveness should be monitored as part of the provider’s quality improvement program, in accordance with

12VAC35-105-620.

Further information and resources related to root cause analysis are located at: http://www.dbhds.virginia.gov/assets/doc/QMD/OL/root-cause-analysis-training-(november-2020).pdf

1. The provider shall develop and implement a root cause analysis policy for determining when a more detailed root cause analysis, including convening a team, collecting and analyzing data, mapping processes, and charting causal factors, should be conducted. At a minimum, the policy shall require for the provider to conduct a more detailed root cause analysis when:

a. A threshold number, as specified in the provider’s policy based on the provider’s size, number of locations, service type, number of individuals served, and the unique needs of the individuals served by the provider, of similar Level II serious incidents occur to the same individual or at the same location within a six month period; b. Two or more of the same Level III serious incidents occur to the same individual or at the same location within a six month period; c. A threshold number, as specified in the provider’s policy based on the provider’s size, number of locations, service type, number of individuals served, and the unique needs of the individuals served by the provider, of similar Level II or Level III serious incidents occur across all of the provider’s locations within a six month period; or d. A death occurs as a result of an acute medical event that was not expected in advance or based on a person’s known medical condition.

Guidance:

Providers must include within their RCA policy the criteria that will be used to determine whether a more detailed RCA is warranted.

When developing the RCA policy, providers should take into consideration the number of locations, the number of individuals receiving services, the type of services the provider provides, and the unique needs of the individuals.

REVISED.DBHDS, LIC17, November 2020 13

F. The provider shall make available and, when requested, submit reports and information that the department requires to establish compliance with these regulations and applicable statutes.

Guidance:

Throughout the course of inspections and investigations, whether on-site, in-person, or via email, phone, letter, or other means of communication, DBHDS will request documentation, including documents relating to an individual’s death, to determine the provider’s compliance with regulations.

Examples of Non-Compliance: o Failure to provide information or documentation requested by DBHDS to determine compliance with regulations. o Failure to submit information requested by licensing staff.

G. Records that are confidential under federal or state law shall be maintained as confidential by the department and shall not be further disclosed except as required or permitted by law; however, there shall be no right of access to communications that are privileged pursuant to §

1. 01-581.17 of the Code of Virginia.

H. Additional information requested by the department if compliance with a regulation cannot be determined shall be submitted within 10 business days of the issuance of the licensing report requesting additional information. Extensions may be granted by the department when requested prior to the due date, but extensions shall not exceed an additional 10 business days.

Guidance:

Throughout the course of inspections and investigations, DBHDS will request documentation, including documents relating to an individual’s death, to determine the provider’s compliance with regulations. In some instances, DBHDS may not be able to determine the provider’s compliance based on information already received and will request additional information.

The provider must submit this documentation and any requested information to DBHDS within 10 business days of the issuance of the licensing report requesting additional information per

12VAC35-105-160.H.

Examples of Non-Compliance: o Failure to provide information or documentation requested by DBHDS to determine compliance with regulations. o Not submitting the information to the Office of Licensing within 10 business days of issuance of a licensing report that requested additional information when no extension was granted in accordance with subsection H.

I. Applicants and providers shall not submit any misleading or false information to the department.

Guidance:

DBHDS may take negative action against any provider that submits written or oral false or misleading information, documents, or reports to DBHDS.

REVISED.DBHDS, LIC17, November 2020 14

J. The provider shall develop and implement a serious incident management policy, which shall be consistent with this section and which shall describe the processes by which the provider will document, analyze, and report to the department information related to serious incidents.

Guidance:

Providers must develop and implement a written policy that describes how the provider will ensure compliance with this section.

The provider’s serious incident management policy should address how the provider will: o Collect, maintain, and review all serious incidents including Level I serious incidents at least quarterly; o Document persons identified by individuals to receive notification of serious incidents and ensure that individual’s authorized representatives, and anyone else identified by the individual receives notification of serious incidents within 24 hours; and o Ensure that Level II and Level III serious incidents are reported to DBHDS within required timeframes.

REVISED.DBHDS, LIC17, November 2020 1

DBHDS Office of Licensing Guidance for Serious Incident Reporting

Effective: November 28, 2020

Purpose: This guidance explains “serious incident” definition and reporting requirements to ensure compliance with the US DOJ Settlement Agreement in 12VAC35-105. For more, see the August 22, 2020, Incident Reporting Memo.

Regulations addressed: Note all regulatory language is formatted in italics while guidance language is in plain text located within boxes under the label “guidance.” 12VAC35-105-20. Definitions. 12VAC35-105-160. Department reviews; information requests; reporting requirements.

12VAC35-105-20. "Serious incident" is any event that causes or could cause harm to an individual’s health, safety, or well-being, including death and serious injury. "Level I" occurs during service or on premises, does not meet Level II/III, and may involve minor injuries or potential for serious injury without actual harm.

Guidance:

Providers are not required to report Level I serious incidents via CHRIS to the Office of Licensing.

Level I incidents occur during active service or on premises. For example, a minor bicycle fall at a group home does not require the case manager to review it for quality improvement, but the licensed group home must collect and review such info.

REVISED.DBHDS, LIC17, November 2020 2

"Level II serious incident" is a service or on-premises incident causing significant harm or threat to an individual’s health or safety, not meeting Level III criteria.

Level II incidents include significant harm or threat caused by an individual to others.

Guidance:

Level II incidents occur during active service or on premises. If notified of incidents outside active service, providers are not required to report, e.g., a car accident ER visit reported later.

Residential providers offer 24-hour support. If a Level II incident occurs during another provider’s active service, the residential provider can verify report submission with the other provider and document attempts.

Verification can be via phone, face-to-face, email, or fax.

Confirmation of report submission from the other provider suffices; if unavailable, file a complaint. For example, verify reports after injuries at day programs; report injuries during independent trips.

If an individual is temporarily away on a family trip and experiences a Level II incident, it does not need to be reported.

REVISED.DBHDS, LIC17, November 2020 3

For example, a choking incident requiring intervention during a family trip does not need reporting if reported by family; internal documentation and support review are advised.

“Level II serious incident” also includes a significant harm or threat to the health or safety of others caused by an individual. o Peer to peer incidents that result in significant harm or threat to the health or safety of an individual by an another individual should be reported to the Office of Licensing as two separate Level II serious incidents in the CHRIS reporting system.
For example, if Individual #1 punches Individual #2 and Individual #2 sustains a broken nose, this Level II serious incident should be reported into CHRIS as a Level II serious incident for Individual #1 because that person caused significant harm to another individual. This incident should also be reported as a Level II serious incident for Individual #2 because that person sustained a serious injury.

Incidents causing significant harm must be reported to the Office of Human Rights and investigated per 12VAC35-115-50. Non-harm peer incidents do not require Level II reporting.

Guidance:

Per Virginia § 1-218, “includes” means “but not limited to,” so Level II incidents are not limited to listed examples.

1. A serious injury;

Guidance:

“Serious injury” is any injury requiring medical attention by a licensed health professional.

1. An individual who is or was missing;

Guidance:

“Missing” means an individual is absent without explanation, not accounted for by supervision needs or behavior pattern.

REVISED.DBHDS, LIC17, November 2020 4

Missed appointments do not need reporting; e.g., missed outpatient or case management appointments are not considered missing.

1. An emergency room visit;

Guidance:

ER visits, excluding licensed emergency services, during provider services or on premises, are Level II incidents.

If EMTs recommend ER but individual declines, no report is needed; no ER visit occurred.

If a Level II incident prompted the call, it should be reported as a Level II incident.

For example, a choking incident requiring intervention and 911 call, but individual refuses ER, still reports as Level II incident due to intervention.

Refusal of care at ER still requires reporting as a Level II incident, as ER visit occurred.

1. An unplanned psychiatric or medical hospital admission of a service recipient, excluding licensed emergency services, except WRAP psychiatric admissions are not unplanned for this Chapter;

Guidance:

If an individual is admitted for psychiatric services per their Wellness Recovery Action Plan (WRAP), the admission is not unplanned and need not be reported.

If an individual only receives licensed emergency services at the time of an unplanned psychiatric admission, the provider is not required to report it. o “Emergency service” includes crisis intervention, stabilization, referral, walk-ins, home visits, jail interventions, and preadmission screening, available 24/7.

REVISED.DBHDS, LIC17, November 2020 5

If an individual is receiving services from a provider other than an emergency service provider (e.g., residential service, day support, mental health community support), and the individual experiences an unplanned psychiatric admission while the provider is actively providing a service to the individual, the provider is required to report the unplanned admission. o For example:
An individual living in a group home experiences a psychiatric crisis while in the group home that leads to the issuance of a TDO and an unplanned hospital admission. The group home provider would be required to report the incident.
During a treatment session, an outpatient service provider is concerned about an individual’s suicidal intent; the provider arranges to have the individual evaluated and then the individual is admitted to the hospital. The outpatient provider would report the incident.
If an individual who receives outpatient services experiences suicidal thoughts at a time when the individual is not in a therapy session with the outpatient service provider and the individual contacts emergency services and ultimately experiences an unplanned psychiatric admission, then neither the outpatient service provider nor the emergency service provider would be required to report the incident.

Case managers must report unplanned psychiatric or medical hospitalizations only if occurring while actively providing case management.

Providers must report unplanned medical admissions if the incident occurred during service provision; otherwise, no report is needed.

1. Choking incidents requiring direct physical intervention;

Guidance:

Providers must report choking incidents requiring physical aid, such as Heimlich, back blows, airway clearing, or CPR.

If an individual coughs up food without aid, no Level II report is required, but record as Level I due to potential for serious injury.

1. Ingestion of any hazardous material;

Guidance:

Providers must report as Level II if an individual ingests or absorbs harmful or threatening materials.

REVISED.DBHDS, LIC17, November 2020 6

The DBHDS safety alert “Hazards of Household Products” provides additional guidance about hazardous materials.

7. A diagnosis of:

a. Decubitus ulcer or increased severity of a previously diagnosed ulcer;

Guidance:

Decubitus ulcer diagnosis or increased severity must be reported as Level II after medical diagnosis.

Providers should review the DBHDS alert on “pressure ulcers” for level definitions. b. Bowel obstruction; or

Guidance:

Bowel obstruction diagnosis must be reported as Level II after medical diagnosis.

Providers should review the DBHDS alert on “constipation.” c. Aspiration pneumonia.

Guidance:

Aspiration pneumonia diagnosis must be reported as Level II after medical diagnosis.

Providers should review the DBHDS alert on “dysphagia/aspiration.”

"Level III serious incident" means any serious incident, regardless of occurrence location or service provision, resulting in:

“[W]hile in the provision of a service” means that an incident occurs when the provider is actively providing a service to the individual.

All Level III incidents must be reported regardless of location or active service provision.

Providers aware of a Level III incident affecting a recipient must report it, even if duplicative. 1) Any death of an individual;

Guidance:

REVISED.DBHDS, LIC17, November 2020 7

All providers, including case managers, must report any death of a recipient at the time of death. For example, both in-home supports and case managers must report if notified of a death over the weekend. 2) A sexual assault of an individual;

Guidance:

Sexual assaults required by law to be reported to authorities must be reported accordingly.

Providers must report any sexual assault of a recipient alleged to result from acts or omissions by staff or responsible persons.

Providers must report to DBHDS any alleged sexual assault of a minor or incapacitated adult.

DBHDS emphasizes trauma-informed, respectful reporting to protect therapeutic relationships.

For adults with capacity: report to DBHDS if assault occurs during service or on premises; if outside, report only with adult’s consent. 3) A suicide attempt by a non-emergency admitted individual resulting in hospitalization.

Guidance:

12VAC35-105-20 defines “suicide attempt” as nonfatal, self-directed behavior with intent to die, regardless of injury.

If an individual admitted for services is hospitalized due to self-directed behavior with intent to die, all providers must report this as a Level III serious incident, regardless of location.

Self-injurious behavior without intent to die causing hospital or ER visit need not be reported as Level III but must be reported as Level II if occurring during or on provider property.

REVISED.DBHDS, LIC17, November 2020 8

Providers must report a suicide attempt resulting in hospital admission if the individual is already admitted or receiving licensed services at the time, regardless of location or active service provision.

If only licensed emergency services are provided at the time of a suicide attempt, reporting is not required.

REVISED.DBHDS, LIC17, November 2020 9

12VAC35-105-160. Reviews by the department; requests for information; required reporting.

A. The provider shall permit department representatives to conduct reviews of:

1. Verify application information;

1. Assure compliance with this chapter; and
2. Investigate complaints.

B. Providers shall fully cooperate with inspections, investigations, and provide all requested information.

Guidance:

DBHDS representatives will request documentation, including death records, to verify provider compliance with regulations.

Examples of Non-Compliance: failure to provide requested information or documentation to DBHDS.

C. Providers shall quarterly collect, maintain, and review all serious incidents, including Level I, as part of quality improvement per 12VAC35-105-620, analyzing trends, systemic issues, remediation, and mitigation steps.

Guidance:

Monitoring Level I, II, and III incidents aims to minimize future serious incidents.

Quality improvement plans per 12VAC35-105-620 must identify trends, systemic issues, remediation, and mitigation steps to reduce future incidents.

Example: quarterly review of Level I incidents identified several falls without serious injury.

1. Trend analysis includes reviewing falls, environment, time, and patterns to identify systemic issues and inform solutions.

1. Provider reviews fall prevention policies, procedures, and environment factors like rugs or furniture that may cause systemic fall risks.

REVISED.DBHDS, LIC17, November 2020 10

1. Provider recommends measures to prevent recurrence, such as placing fall mats near beds based on trend analysis.

1. Provider documents actions taken to reduce future incident risks.

For more info, see DBHDS Office of Licensing, Guidance for Quality Improvement.

D. Providers shall collect, maintain, and report or make available the following information:

1. Each allegation of abuse or neglect shall be reported to the department as provided in

12VAC35-115-230 A.

Guidance:

Providers shall report abuse or neglect allegations via CHRIS Human Rights within 24 hours of receipt.

[NOTE: This is not a change]

1. Level II/III incidents must be reported via web, phone, or email within 24 hours, including date, location, circumstances, injuries, death details, and consequences; hospital deaths are reportable.

Guidance:

Level II and III serious incidents must be reported via CHRIS Licensing within 24 hours of discovery.

Providers must also report Level II and III incidents to guardians or authorized reps within 24 hours of discovery.

Providers must report deaths if the individual was still in service at death.

REVISED.DBHDS, LIC17, November 2020 11

1. Instances of seclusion or restraint shall be reported to the department as provided in

12VAC35-115-230 C 4.

Guidance:

Providers must report non-compliant seclusion/restraint or injury to DBHDS via CHRIS within 24 hours; notify the individual’s authorized rep if applicable.

[NOTE: This is not a change.] E. A root cause analysis shall be conducted by the provider within 30 days of discovery of Level II serious incidents and any Level III serious incidents that occur during the provision of a service or on the provider's premises.

Guidance:

“Root cause analysis” (RCA), per 12VAC35-105-20, is a method to identify underlying causes, focusing on systems, processes, and outcomes needing change to reduce harm.

RCA focuses on systems, processes, and outcomes, not individuals. It aims to determine what, why, and if action is needed, including documentation of these elements as known or knowable.

1. Root cause analysis must include at least a detailed description of the incident;

Guidance:

Documentation should include the event sequence, immediate actions, and an analysis of causes within the provider’s control.

Guidance:

Analysis of why an incident occurred should:

1. Compare actual events to expected actions before, during, and after the incident.
2. Compare actions before, during, and after to policies, regulations, standards, and laws.
3. Identify provider-controlled underlying causes of the incident.

REVISED.DBHDS, LIC17, November 2020 12

c. Identified solutions to prevent recurrence and reduce future harm when applicable.

Guidance:

The RCA should identify solutions for the provider to prevent recurrence or minimize future harm.

Solutions must be individual-specific and systemic per incident analysis, monitored through the provider’s quality improvement program, in accordance with

12VAC35-105-620.

Resources on root cause analysis are at: http://www.dbhds.virginia.gov/assets/doc/QMD/OL/root-cause-analysis-training-(november-2020).pdf

1. Provider shall develop a root cause analysis policy requiring detailed analysis, including team convening, data collection, process mapping, and causal factor analysis, when:

a. A provider-defined threshold, based on size, locations, services, and needs, of similar Level II incidents at the same individual or location within six months; b. Two or more of the same Level III incidents at the same individual or location within six months; c. A provider-defined threshold, considering size, locations, services, and needs, of similar Level II or III incidents across all locations within six months; or d. An unexpected death from an acute medical event or known condition.

Guidance:

Providers must include criteria in their RCA policy to determine when a more detailed RCA is needed.

When developing the RCA policy, providers should consider locations, individuals served, service types, and individual needs.

REVISED.DBHDS, LIC17, November 2020 13

F. The provider shall make available and submit reports and information upon request to establish compliance with regulations and statutes.

Guidance:

During inspections and investigations, DBHDS will request documentation, including death-related documents, to assess compliance, via any communication method.

Examples of Non-Compliance: failure to provide or submit requested information or documentation to DBHDS or licensing staff.

G. Confidential records under federal or state law shall be maintained as such and not disclosed except as permitted by law; privileged communications under §

1. Virginia Code § 1-581.17.

H. Additional info requested if compliance is unclear must be submitted within 10 business days of the licensing report; extensions may be granted if requested beforehand, up to 10 days.

Guidance:

During inspections, DBHDS will request documentation, including death-related documents, to assess compliance; additional info may be requested if needed.

The provider must submit requested documentation within 10 business days of the licensing report.

12VAC35-105-160.H.

Examples of Non-Compliance: failure to provide requested information within 10 days of the licensing report when no extension was granted.

I. Applicants and providers shall not submit any misleading or false information to the department.

Guidance:

DBHDS may take action against providers submitting false or misleading information or reports.

REVISED.DBHDS, LIC17, November 2020 14

J. The provider shall develop and implement a serious incident management policy detailing documentation, analysis, and reporting processes to the department.

Guidance:

Providers must develop and implement a written policy ensuring compliance with this section.

The policy should address: quarterly review of all serious incidents including Level I; documenting notification recipients and ensuring they are notified within 24 hours; and reporting Level II and III incidents to DBHDS timely.

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD08) Page 1 of 8 COMMONWEALTH of VIRGINIA DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES Post Office Box 1797 Richmond Virginia 23218-1797 Telephone (804) 786-3921 Fax: (804) 371-6638 www.dbhds.virginia.gov

Case Management Operational Guidelines 2022

People with developmental disabilities who are most at risk benefit from more frequent case manager/support coordinator face-to-face visits due to the complexity of their support needs. The “Case Management Operational Guidelines” were developed by a committee of community services boards (CSB), DD Waiver staff, and advocacy community representatives. The guidelines provide historical information, including two additional updates from April 2014 and January 2017. This document is designed to incorporate past guidance in a simplified, redesigned format.

These operational guidelines are intended to assist CSB DD case managers (hereafter referred to as support coordinators or SC/CM) in implementing the case management requirements of enhanced case management. Enhanced case management requires the following:

1. For individuals receiving case management/support coordination services, the individual’s SC/CM shall meet with the individual face-to-face on a regular basis and shall conduct regular visits to the individual’s residence, as dictated by the individual’s needs.

2. At these face-to-face meetings, the case manager/support coordinator shall:

 observe the individual and the individual’s environment to assess for previously unidentified risks, injuries, needs, or other changes in status;  assess the status of previously identified risks, injuries, needs, or other change in status;  assess whether the individual’s support plan is being implemented appropriately and remains appropriate for the individual; and  ascertain whether supports and services are being implemented consistent with the individual’s strengths and preferences and in the most integrated settings appropriate to the individual’s needs.

If any of these observations or assessments identifies an unidentified or inadequately addressed risk, injury, need, or change in status, a deficiency in the individual’s support plan or its implementation, or a discrepancy between the implementation of supports and services and the individual’s strengths and preferences, the SC/CM shall report and document the issue, convene the individual’s service planning team to address it, and document its resolution.

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD 08) Page 2 of 8 To “report and document the issue” and meet requirements, the SC/CM must take the following actions:

a. Document in the record the specific unidentified or inadequately addressed risk, injury, need, or change in status, including the report to and the response of the designated provider(s).

b. Convene and mobilize person-centered planning (PCP) team members needed to address the issue and revise the ISP as needed. The meeting will include the individual, guardian/authorized representative (AR), if applicable, case manager/support coordinator, and applicable providers.

The meeting can be in person, a video meeting, a formal scheduled conference call, and/or an informal SC/CM initiated telephone call with the relevant parties.

c. Report suspected abuse, neglect, or exploitation to Adult Protective Services (APS) or Child Protective Services (CPS) and the DBHDS Office of Human Rights (OHR) according to agency policies and regulations.

d. Report to the DBHDS Office of Licensing (OL) serious incidents or injuries as defined in licensure according to agency policies and regulations.

e. Report the individual’s PCP team’s inability to achieve resolution within a reasonable time (2 weeks) by following SC/CM agency policies and by contacting the CRC and the DBHDS Office of Licensing as needed.

f. Document the issue and resolution of the issue in the case manager/support coordinator record.

g. When an issue is related to a health or crisis event, the SC/CM monitors implementation of the ISP (including safety and risk mitigation protocols) to ensure the ISP is implemented as written to reduce the potential of a future crisis event. Any crisis event includes the need for the SC/CM to document the issue, convene relevant team members, revise the ISP, report suspected abuse, neglect, and/or exploitation to APS/CPS/OHR/OL as defined in regulations, and document the resolution. SC/CMs also communicate concerns to their supervisors and follow their agencies’ policies and procedures in responding.

1. The individual’s case manager/support coordinator shall meet with the individual face-to-face every 90 days. For individuals that are receiving enhanced case management (ECM), these visits must occur at least one time per calendar month, with no more than 40 days between visits. For example, if an ECM visit occurs on March 2, the next visit is due on or before April 11th. There are 40 days from March 2 nd to April 11 th and this timeframe enables one visit to occur in both calendar months.

At least one such visit every two months must be in the individual’s place of residence for any individuals who:

1. Have transitioned from a training center within the previous 12 months;

1. Receive services from providers having conditional or provisional licenses;

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD 08) Page 3 of 8

1. Have an interruption of service greater than 30 days (excludes a break in employment when the individual is in supported employment and remains with the same supported employment provider);

1. Have an inability to access needed therapeutic services, assistive technology, environmental modification, or behavioral consultation;

1. Encounter the crisis system, criminal justice system, or have APS involvement;

1. Reside in congregate settings of 5 or more individuals**;

1. Have any items under 1a or 1b scored with a 2 on the Supports Intensity Scale ® (SIS ®)**

• exceptions described in the chart below To assist with determining when to intiate and cease the provision of ECM, DBHDS has developed, in collaboration with CSBs, an automated ECM Worksheet that is available on the DBHDS website at https://dbhds.virginia.gov/wp-content/uploads/2022/09/CM-Worksheet-FINAL-11.3.21-1.xlsx.

The On-site Visit Tool (OSVT) must be completed at one face-to-face visit monthly for people receiving ECM and once quarterly for people receiving targeted case management (TCM) and uploaded into the Waiver Management System under the Person’s Information attachments section. This form provides a means to ensure that consistency is applied when assessing for any “change in status” and to confirm that the services are “implemented appropriately.” Based on observation and report, include specific, detailed notes in the person’s record about the findings and any actions that will be taken (including the need for any additional assessments, such as behavioral and/or medical reviews, or root cause analysis, to understand and address identified concerns). If the person has lost a service as a result of behavioral or medical issues or a provider’s perception of increased needs, additional assessment from a qualified professional or the exploration of alternate services/providers are necessary to determine how the individual’s needs can met.

Case managers/support coordinators must ensure that there is a corresponding note in the individual’s record that includes additional actions or follow-up as identified on the OSVT. When scoring each section (Change in Status and Services Implemented Appropriately), if there is a concern noted on any of the questions in each of these two sections, this affects final scoring. For example, if there is an answer of ‘yes’ to any of questions 1 - 5 in “Change in Status” , this indicates a change in status. Similarly, an answer of ‘no’ to any of questions 7 – 13 under “Services Implemented Appropriately” indicates services are not appropriately implemented. Information from the completion of the OSVT should be incorporated into the quarterly Person-Centered Review.

Explanation of Population Served

All individuals with developmental disabilities who receive HCBS waiver services and who meet the criteria established in this guidance require more frequent face-to-face visits at least every thirty (30) days.

Individuals receiving HCBS waiver services include Building Independence (BI), Family and Individual Support (FIS), Community Living (CL) waiver recipients, as well as people receiving Commonwealth Coordinated Care (CCC) Plus Waiver who are on the DD Waiver wait list and have targeted case

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD 08) Page 4 of 8 management. Thus, the CSB DD case manager/support coordinator must provide the more frequent face-to-face visits at least every thirty (30) days to individuals who are on the DD waiver or the DD waiver wait list with Commonwealth Coordinated Care (CCC) Plus waiver, AND meet any of the criteria one through seven above.

Table 1 below shows which groups must receive face-to-face visits at least every (30) days, if they meet any of the criteria.

Inability to Complete Required Visits If the case manager/support coordinator cannot complete the required face-to-face contact, he/she must document the reason(s) and all attempts. After two consecutive 30-day periods of no contact, the CSB case manager/support coordinator will notify their supervisor to determine if further steps are needed (such as contacting the licensing specialist, DMAS, CRC, etc.). The CSB case manager/support coordinator must also comply with the established Waiver “Request to Retain Slot” process as appropriate.

Compliance with these standards will be through routine Licensing reviews of case management services, quality service reviews, and as part of the investigation review process for both Licensing and Human Rights.

Exceptions The following chart provides a description of the removal of ECM criteria to include exceptions where applicable.

Table 1: Population 30 day visists required IF any of the criteria of are met BI Waiver Recipients Yes FIS Waiver Recipients Yes CL Waiver Recipients Yes Individuals on DD Waiver Wait List who are receiving CCC+ Waiver Services and who have Targeted Case Management Yes Individuals on the DD Waiver Wait List who do not have CCC+ No Individuals in Training Centers No Individuals in Community-Based ICFs No Individuals in NFs No

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD08) Page 5 of 8 Enhanced Case Management Criteria and Considerations

When to Begin ECM When to Stop ECM Considerations

A.

The person left a training center in the last 12 months.

The person has been stable in their new home for at least 12 months.

SC/CMs can complete a post-move monitoring report or send their notes from the visits that occur at 30, 60, and 90 days detailing their review of the provision of essential supports and notes for the first year to the post move monitor. Post move monitor should be notified of a change in provider if it occurs during the first year for individuals with SIS level 1-4 or during the first 2 years for individuals with a SIS level of 5-7 because that's how long DBHDS actively follows people who are discharged from a training center.

B.

The person receives services from any provider w/ conditional or provisional license. 90 days have passed since the removal of the conditional or provisional status.

License type can be located through the Office of Licensing Provider Search, by selecting License Type from the drop down menu here.

C.

An interruption of 30 days or longer for any DD waiver service (excludes a break in employment when the individual is in Supported Employment and remains with the same supported employment provider).

When services have resumed.

An individual choosing not to attend or participate in a service is not considered an interruption. This means a break in an authorized service due to factors beyond the individual's control such as programmatic issues, staffing, or medical events that led to the break in services for any of the following waiver services: i. Congregate residential (including supervised [group home] and sponsored residential) ii. In-home residential iii. Personal assistance (agency-directed or consumer-directed) iv. Supported employment (Change in SE job site but not provider does not constitute interruption in service) v. Day services (e.g. group day support, community engagement, community coaching, and workplace assistance)

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD 08) Page 6 of 8

D.

There is an inability to access needed therapeutic services, adaptive equipment, or environmental modification that have been recommended by a professional.

Needed services have been identified/obtained.

N/A E1. The person encounters the crisis system and/or the medical health system for admission or assessment (for unplanned and emergency related events).

When the person has recovered from the crisis and/or medical concerns and has been stable† for at least 90 days or there are unique circumstances that a supervisor confirms* warrants an exception to ECM.

Crisis services include: REACH Crisis Therapeutic Home (CTH), Adult or Child Crisis Stabilization Unit (CSU), unplanned crisis stabilization services (if mobile crisis comes out once and doesn’t refer to consultation or other REACH services, then ECM is not required), emergency services, children’s crisis or REACH services, hospital (other than for routine or elective procedures) and ER visits, hospitalization followed by an admission to a long term rehabilitation or skilled nursing facility or unplanned stay, ECM is initiated upon admissionto the facility. A stay in a state facility such as Central State Hospital is different and ECM would not be provided during this stay.

SC/CM must document the reason ECM is not provided in any instance. Some known causes of unplanned medical emergencies: the diagnosis of aspiration pneumonia, bowel obstruction, seizures, decubitus ulcer (pressure sore), UTI, seizure, falls, and sepsis.

E2. There has been APS or CPS involvement.

The APS/CPS case has been closed without further risk to the person for at least 90 days or there are unique circumstances that a supervisor confirms* warrant an exception to ECM.

N/A E3. The person has encountered the criminal justice system or has been incarcerated.

Criminal charges have been resolved with no additional concerns for at least 90 days or there are unique circumstances that a supervisor confirms* warrant an exception to ECM.

ECM is not required during periods of incarceration other than for the 60 days immediately prior to release to assist with reintegration efforts.

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD 08) Page 7 of 8

F.

The person lives in a group home with 5 or more beds.

This the only ECM criteria met and the person has been medically and behaviorally stable† with successful supports for the past 12 months with no new risks (medical and/or behavioral) identified in the last 12 months.

Safety protocols/mitigation plans (health and safety outcomes/risk protocols/behavior plans) are in place as evidenced by:

1. The ISP includes safety protocols and mitigation plans for identified intensive medical and behavioral needs.The ISP is updated appropriately.

1. Safety protocols/mitigation plans are followed by the provider.

1. SC/CM reviews provider documentation of safety protocols and mitigation plans to ensure they are implemented as written.

1. The safety protocols/mitigation plans (health and safety outcomes/risk protocols/behavior plans) are reviewed quarterly and revised as needed.

If the individual were to meet any other ECM criteria, this exemption does not apply and ECM would continue. If someone moves from a 5 bed home to another 5 bed home and they were stable before the move and remain stable for 12 months and no new risks are identified then ECM is not required.

Please note ECM criteria is based on the number of people for which the home is licensed and not the number of people actually living in the home.

Licensed home size can be confirmed by contacting the DBHDS Office of Licensing as needed.

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD 08) Page 8 of 8

G.

Any item(s) under 1a or 1b on the SIS® are scored with a 2.

There is clinical documentation that establishes that items no longer meet 1a or 1b since the completion of the SIS® and no new needs have been identified that meet the same criteria or this the only ECM criteria met (from A through G) and the person experienced no concerns related to the identified health conditions in the past 12 months. or the person only receives Therapy Services as identified on 1a of the SIS® with no other items under 1a or 1b scored a 2 or the only item identified is "Fall Risk" with no injury in the last 90 days.

If the individual has experienced an injury as a result of an adverse event in the context of lifting or transferring in the past 90 days, then ECM is required and will continue for 90 days after the individual is stabilized.

• It is expected that these situations will be infrequent and should clearly document supervisory review and why an exception is being made. If an exception is appropriate, the SC must still review all criteria before determining if the individual qualifies or not for ECM.

†Stability is defined as pre injury/illness condition/functioning or the individual has reached post injury/illness, condition or optimum functioning as determined by a licensed medical professional (primary care provider (PCM), nurse practioner (NP), registered nurse (RN), physician assistant (PA)).

While in writing from the professional would be preferable, documentation by the SC/CM is sufficient when it includes the details of the conversation with those involved and confirms that a professional made the determination.

DBHDS has provided a training video available at https://vimeo.com/manage/videos/673185115/22a1ae3289, as well as a Frequently Asked Questions document to assist with specific scenarios that have been encountered. This document is available online at https://dbhds.virginia.gov/wp-content/uploads/2022/09/ECM-Question-Answers-Final-9.26.22-1.pdf. Additional guidance is available in the DD Support Coordination Handbook at https://dbhds.virginia.gov/assets/doc/sccm/dd-sc-manual-12202021-rev-2-final.pdf or by contacting your Provider Development System Team Community Resource Consulant (CRC). CRC contact information is available online at https://dbhds.virginia.gov/developmental-services/provider-development/.

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD08) Page 1 of 8 COMMONWEALTH of VIRGINIA DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES Post Office Box 1797 Richmond Virginia 23218-1797 Telephone (804) 786-3921 Fax: (804) 371-6638 www.dbhds.virginia.gov

Case Management Operational Guidelines 2022

People with developmental disabilities who are most at risk benefit from more frequent case manager/support coordinator face-to-face visits due to the complexity of their support needs. The “Case Management Operational Guidelines” were developed by a committee of community services boards (CSB), DD Waiver staff, and advocacy community representatives. The guidelines provide historical information, including two additional updates from April 2014 and January 2017. This document is designed to incorporate past guidance in a simplified, redesigned format.

These guidelines assist CSB DD case managers (support coordinators or SC/CM) in implementing enhanced case management requirements, which include:

1. For individuals receiving case management/support coordination, the SC/CM shall meet face-to-face regularly and conduct visits to the individual's residence based on needs.

2. At these face-to-face meetings, the case manager/support coordinator shall:

 Observe the individual and environment for new risks, injuries, needs, or changes;  assess the status of known risks, injuries, needs, or changes;  evaluate if the support plan is properly implemented and suitable;  ensure supports and services align with strengths, preferences, and are in the most integrated settings.

If any observation or assessment finds an unaddressed risk, injury, need, change, support plan deficiency, or discrepancy with strengths and preferences, the SC/CM must report, document, convene the team, and record resolution.

December 2022 – Case Management Guidelines Revised, Eff. 3/2/23 (DD 08) Page 2 of 8 To report and document issues, the SC/CM must:

a. Record in the case file the specific unaddressed risk, injury, need, or change, including provider reports and responses.

b. Convene PCP team members to address the issue and revise the ISP as needed, including the individual, guardian/AR if applicable, support coordinator, and providers.

Meetings may be in person, via video, scheduled conference call, or informal SC/CM phone call with relevant parties.

c. Report suspected abuse, neglect, or exploitation to APS or CPS and the DBHDS Office of Human Rights (OHR) per agency policies.

d. Report serious incidents or injuries to the DBHDS Office of Licensing (OL) as defined in licensure, per agency policies.

e. Report to agency policies and contact CRC and OL if the PCP team cannot resolve issues within 2 weeks.

f. Record the issue and resolution in the case file.

g. When an issue is related to a health or crisis event, the SC/CM monitors implementation of the ISP (including safety and risk mitigation protocols) to ensure the ISP is implemented as written to reduce the potential of a future crisis event. Any crisis event includes the need for the SC/CM to document the issue, convene relevant team members, revise the ISP, report suspected abuse, neglect, and/or exploitation to APS/CPS/OHR/OL as defined in regulations, and document the resolution. SC/CMs also communicate concerns to their supervisors and follow their agencies’ policies and procedures in responding.

1. The individual’s case manager/support coordinator shall meet with the individual face-to-face every 90 days. For individuals that are receiving enhanced case management (ECM), these visits must occur at least one time per calendar month, with no more than 40 days between visits. For example, if an ECM visit occurs on March 2, the next visit is due on or before April 11th. There are 40 days from March 2 nd to April 11 th and this timeframe enables one visit to occur in both calendar months.

At least one visit every two months must occur at the individual’s residence for:

1. Have transitioned from a training center within the previous 12 months;

1. Receive services from providers having conditional or provisional licenses;

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD 08) Page 3 of 8

1. Have a service interruption over 30 days (excluding breaks in supported employment with the same provider);

1. Unable to access needed therapeutic services, assistive technology, environmental modifications, or behavioral consultation;

1. Encounter the crisis system, criminal justice system, or have APS involvement;

1. Reside in congregate settings of 5+ individuals**;

1. Have items under 1a or 1b scored as 2 on the SIS®**

• Exceptions in the chart below; DBHDS, with CSBs, developed an automated ECM Worksheet at https://dbhds.virginia.gov/wp-content/uploads/2022/09/CM-Worksheet-FINAL-11.3.21-1.xlsx to help determine when to start or stop ECM.

The OSVT must be completed during one face-to-face monthly visit for ECM and quarterly for TCM, uploaded into the Waiver System. It ensures consistency in assessing status changes and service implementation. Notes must detail findings and actions, including additional assessments if needed due to service loss or increased needs.

Support coordinators must record OSVT findings, including follow-up actions. Concerns in 'Change in Status' (yes to Q1-5) or 'Services Implemented' (no to Q7-13) affect scoring. OSVT info should be included in quarterly reviews.

Explanation of Population Served

All individuals with developmental disabilities receiving HCBS waiver services who meet this guidance’s criteria require face-to-face visits at least every 30 days.

Individuals receiving HCBS waiver services include Building Independence (BI), Family and Individual Support (FIS), Community Living (CL) waiver recipients, as well as people receiving Commonwealth Coordinated Care (CCC) Plus Waiver who are on the DD Waiver wait list and have targeted case

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD 08) Page 4 of 8 management. Thus, the CSB DD case manager/support coordinator must provide the more frequent face-to-face visits at least every thirty (30) days to individuals who are on the DD waiver or the DD waiver wait list with Commonwealth Coordinated Care (CCC) Plus waiver, AND meet any of the criteria one through seven above.

Table 1 indicates groups requiring face-to-face visits at least every 30 days if criteria are met.

If the support coordinator cannot complete required visits, they must document reasons and attempts. After two missed 30-day visits, notify supervisor for further action, including the Waiver 'Request to Retain Slot' if needed.

Compliance will be assessed via routine licensing reviews, quality reviews, and investigations for Licensing and Human Rights.

Exceptions: The following chart details ECM criteria removals and applicable exceptions.

Table 1: Population 30 day visists required IF any of the criteria of are met BI Waiver Recipients Yes FIS Waiver Recipients Yes CL Waiver Recipients Yes Individuals on DD Waiver Wait List who are receiving CCC+ Waiver Services and who have Targeted Case Management Yes Individuals on the DD Waiver Wait List who do not have CCC+ No Individuals in Training Centers No Individuals in Community-Based ICFs No Individuals in NFs No

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD08) Page 5 of 8 Enhanced Case Management Criteria and Considerations

When to Begin and Stop ECM Considerations

A.

The person left a training center in the last 12 months.

The person has been stable in their new home for at least 12 months.

SC/CMs can complete a post-move monitoring report or send their notes from the visits that occur at 30, 60, and 90 days detailing their review of the provision of essential supports and notes for the first year to the post move monitor. Post move monitor should be notified of a change in provider if it occurs during the first year for individuals with SIS level 1-4 or during the first 2 years for individuals with a SIS level of 5-7 because that's how long DBHDS actively follows people who are discharged from a training center.

B.

The person receives services from a provider with a conditional or provisional license, and 90 days have passed since removal of such status.

License type can be found via the Office of Licensing Provider Search by selecting License Type.

C.

A 30+ day interruption in any DD waiver service (excluding employment breaks in Supported Employment with same provider).

When services have resumed.

An individual choosing not to attend or participate in a service is not considered an interruption. This means a break in an authorized service due to factors beyond the individual's control such as programmatic issues, staffing, or medical events that led to the break in services for any of the following waiver services: i. Congregate residential (including supervised [group home] and sponsored residential) ii. In-home residential iii. Personal assistance (agency-directed or consumer-directed) iv. Supported employment (Change in SE job site but not provider does not constitute interruption in service) v. Day services (e.g. group day support, community engagement, community coaching, and workplace assistance)

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD 08) Page 6 of 8

D.

Inability to access professionally recommended therapeutic services, adaptive equipment, or environmental modifications.

Needed services have been identified/obtained.

E1. The person encounters crisis or medical systems for admission or assessment (unplanned/emergency events).

After recovery and 90+ days stability, or supervisor-confirmed exceptional circumstances, ECM may be waived.

Crisis services include: REACH Crisis Therapeutic Home (CTH), Adult or Child Crisis Stabilization Unit (CSU), unplanned crisis stabilization services (if mobile crisis comes out once and doesn’t refer to consultation or other REACH services, then ECM is not required), emergency services, children’s crisis or REACH services, hospital (other than for routine or elective procedures) and ER visits, hospitalization followed by an admission to a long term rehabilitation or skilled nursing facility or unplanned stay, ECM is initiated upon admissionto the facility. A stay in a state facility such as Central State Hospital is different and ECM would not be provided during this stay.

SC/CM must document why ECM isn't provided. Common causes: aspiration pneumonia, bowel obstruction, seizures, pressure sores, UTI, falls, sepsis.

E2. APS or CPS involvement occurred.

APS/CPS case closed with no risk for 90+ days or supervisor-confirmed exception.

N/A E3. The person has encountered the criminal justice system or has been incarcerated.

Criminal charges resolved with no concerns for 90+ days or supervisor-confirmed exception.

ECM is not required during periods of incarceration other than for the 60 days immediately prior to release to assist with reintegration efforts.

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD 08) Page 7 of 8

F.

The person resides in a group home with 5+ beds.

This is the sole ECM criterion met; the person has been medically and behaviorally stable with successful supports for 12 months, with no new risks.

Safety protocols, mitigation plans, and behavior plans are in place, evidenced by:

1. The ISP includes safety protocols and mitigation plans for identified intensive medical and behavioral needs.The ISP is updated appropriately.

1. Providers follow safety protocols/mitigation plans.

1. SC/CM reviews provider documentation to ensure safety protocols and mitigation plans are implemented as written.

1. Safety protocols/mitigation plans (health, safety, risk, behavior) are reviewed quarterly and revised as needed.

If the individual were to meet any other ECM criteria, this exemption does not apply and ECM would continue. If someone moves from a 5 bed home to another 5 bed home and they were stable before the move and remain stable for 12 months and no new risks are identified then ECM is not required.

ECM criteria are based on licensed home size, not actual residents.

Licensed home size can be confirmed via the DBHDS Office of Licensing.

December 2022 – Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD 08) Page 8 of 8

G.

Items under 1a or 1b on SIS® are scored 2.

Clinical documentation shows items no longer meet 1a or 1b since SIS® completion, with no new needs, or only therapy services under 1a, no other 2s, and no recent injuries related to Fall Risk.

If the individual experienced an injury from an adverse event during lifting or transferring in the past 90 days, ECM is required and continues for 90 days after stabilization.

• It is expected that these situations will be infrequent and should clearly document supervisory review and why an exception is being made. If an exception is appropriate, the SC must still review all criteria before determining if the individual qualifies or not for ECM.

†Stability is defined as pre injury/illness condition/functioning or the individual has reached post injury/illness, condition or optimum functioning as determined by a licensed medical professional (primary care provider (PCM), nurse practioner (NP), registered nurse (RN), physician assistant (PA)).

While written documentation from the professional is preferable, SC/CM documentation is sufficient if it includes conversation details and confirms a professional's determination.

DBHDS provides a training video at https://vimeo.com/manage/videos/673185115/22a1ae3289, an FAQ at https://dbhds.virginia.gov/wp-content/uploads/2022/09/ECM-Question-Answers-Final-9.26.22-1.pdf, guidance in the DD Support Coordination Handbook at https://dbhds.virginia.gov/assets/doc/sccm/dd-sc-manual-12202021-rev-2-final.pdf, or by contacting the Provider Development System Team CRC at https://dbhds.virginia.gov/developmental-services/provider-development/.

COMMONWEALTH of VIRGINIA

NELSON SMITH

COMMISSIONER

DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES Post Office Box 1797 Richmond, Virginia 23218-1797 Telephone (804) 786-3921 Fax (804) 371-6638 www.dbhds.virginia.gov

TO:

Forensic Evaluators Approved by DBHDS to Complete Adult Pretrial Evaluations

FROM: Elizabeth Hunt, Ph.D., ABPP

Forensic Evaluation Manager

DBHDS

DATE: November 15, 2023 SUBJECT: Additional Information on SB1507/HB1908 (DBHDS Guidance Document FOR 06) The 2023 Session of the Virginia General Assembly passed SB1507/HB1908, which modifies Code of Virginia §§ 19.2-169.1 and 19.2-169.2, specifically the portions of the bill that were established under SB198 (2022). As a reminder, the changes from SB198 allowed for, in certain misdemeanor cases when a defendant is found incompetent to stand trial, the court to dismiss the charge(s) and refer the individual for the community services board or behavioral health authority (CSB) for an evaluation to determine whether the defendant meets criteria for temporary detention.

Overview of Changes under SB1507/HB1908 In § 19.2-169.1 (D), the modifications from SB1507/HB1908 are in bold and the code now states that “Upon completion of the evaluation, the evaluators shall promptly submit a report in writing to the court and the attorneys of record concerning (i) the defendant's capacity to understand the proceedings against him; (ii) the defendant's ability to assist his attorney; (iii) the defendant's need for treatment in the event he is found incompetent but restorable, or incompetent for the foreseeable future; and (iv) if the defendant has been charged with a misdemeanor violation of Article 3 (§ 18.2-95 et seq.) of Chapter 5 of Title 18.2 or a misdemeanor violation of § 18.2-119, 18.2-137, 18.2-388, 18.2-415, or 19.2-128, whether the defendant should be evaluated to determine whether he meets the criteria for temporary detention pursuant to § 37.2-809 in the event he is found incompetent but restorable or incompetent for the foreseeable future.” While code language for SB198 indicated that the report “may” recommend that the court direct the CSB to conduct an evaluation to determine whether the defendant meets criteria for temporary detention, SB1507/HB1908 code language now indicates that the report “shall” include whether the defendant should be evaluated to determine whether he meets the criteria for temporary detention. Thus, evaluators are required to include this recommendation in their opinion for applicable cases.

In § 19.2-169.2, the modifications from SB1507/HB1908 apply to sections C and D.

For Section C, the code now states, “Notwithstanding the provisions of subsection A, in cases in which (i) the defendant has been charged with a misdemeanor violation of Article 3 (§ 18.2-95 et Page 2 of 3 Additional Information SB1507/HB1908

seq.) of Chapter 5 of Title 18.2 or a misdemeanor violation of § 18.2-119, 18.2-137, 18.2-388, 18.2-415, or 19.2-128; (ii) the defendant has been found to be incompetent pursuant to subsection E or F of § 19.2-169.1; and (iii) the competency report described in subsection D of § 19.2-169.1 recommends that the defendant be evaluated to determine whether he meets the criteria for temporary detention pursuant to § 37.2-809, the court may order the community services board or behavioral health authority serving the jurisdiction in which the defendant is located to (a) conduct an evaluation of the defendant and (b) if the community services board or behavioral health authority determines that the defendant meets the criteria for temporary detention, file a petition for issuance of an order for temporary detention pursuant to § 37.2-809.

The community services board or behavioral health authority shall notify the court, in writing, within 72 hours of the completion of the evaluation and, if appropriate, file a petition for issuance of an order for temporary detention. Upon receipt of such notice, the court may dismiss the charges without prejudice against the defendant. However, the court shall not enter an order or dismiss charges against a defendant pursuant to this subsection if the attorney for the Commonwealth is involved in the prosecution of the case and the attorney for the Commonwealth does not concur in the motion.

For Section D, the code now states, “If a defendant for whom an evaluation has been ordered pursuant to subsection C fails or refuses to appear for the evaluation, the community services board or behavioral health authority shall notify the court and the court shall issue a mandatory examination order and capias directing the primary law-enforcement agency for the jurisdiction in which the defendant resides to transport the defendant to the location designated by the community services board or behavioral health authority for examination.” The language in SB198 indicated that the court could dismiss the charge(s) against the defendant in lieu of ordering restoration and order the CSB to conduct an evaluation to determine whether the defendant meets criteria for temporary detention. Thus, the dismissal and order to the CSB were occurring at the same time. SB1507/HB1908 provides clarification that these steps now occur in a sequential manner and the charge(s) are not dismissed until the CSB files notice to the court that a temporary detention petition is being filed. The language in section D was completely changed to include the use of law enforcement in transporting individuals who refuse or do not show for the temporary detention evaluation.

Application to Evaluations These modifications went into effect on July 1, 2023. As a reminder, these modifications apply to misdemeanor charges of larceny, trespassing, property/monument damage, disorderly conduct, failure to appear, or drunk in public.

Evaluators are now required to include language in the competency report about whether or not the defendant should be evaluated to determine whether he meets the criteria for temporary detention whenever a defendant is opined incompetent but restorable for the above-mentioned misdemeanor charges. The following steps may be considered when completing competence to stand trial evaluations, though evaluators should also carefully read the Code.

Step 1: Formulate an opinion of the defendant’s competence to stand trial Step 2: If the defendant is incompetent to stand trial, make a determination regarding restorability. Refer to § 19.2-169.1(D) regarding situations when an unrestorable opinion may be offered at the point of the initial competence to stand trial evaluation, such as when the Page 3 of 3 Additional Information SB1507/HB1908

competency is due to an irreversible medical condition or if the defendant has been found unrestorable within the last two years.

If the opinion is that the defendant is incompetent and likely to remain incompetent for the foreseeable future (unrestorably incompetent to stand trial, URIST), then make recommendations pursuant to § 19.2-169.3 (A) and standard procedures apply.

Step 3: If the opinion is that the defendant is incompetent, but restorable, review the defendant’s charges.

Unless the defendant’s charges are solely the misdemeanor charges listed in the Code change, make a recommendation regarding restoration, including whether restoration should occur on an outpatient or inpatient basis. Standard procedures apply.

Step 4: [SB1507/HB1908 Revision] If the charges are one or more of the misdemeanor charges listed in the Code change, then review the civil commitment code sections, as well as § 19.2-169.1 (D) and § 19.2-169.2 (C) and (D). Your report is now required to include language regarding whether the defendant should be evaluated to determine whether he meets the criteria for temporary detention.

If your opinion is that the defendant should be evaluated to determine whether he meets criteria for temporary detention, then include a statement in the opinion section of your report that notifies the court that the defendant should be evaluated to determine whether he meets criteria for temporary detention (you may also consider citing § 19.2-169.1 (D) and § 19.2-169.2 (C) and (D)). You should still include recommendations regarding restoration (including whether restoration should occur on an outpatient or inpatient basis) in the event the court does not pursue this option.

• In cases in which the opinion is that the defendant should be evaluated to determine whether he meets criteria for temporary detention, evaluators are also reminded of their ethical obligation to ensure the individual is safe and should take any additional steps and/or notify the appropriate entities as soon as possible.

If your opinion is that the defendant should not be evaluated to determine whether he meets criteria for temporary detention, then make a recommendation regarding restoration, including whether restoration should occur on an outpatient or inpatient basis. Standard procedures apply.

In summary, the opinion section of your report should include the following (per the referenced code sections):

1. Opinion on whether the defendant is competent or incompetent.
2. Restoration recommendation (outpatient or inpatient).
3. Your recommendation regarding whether or not the defendant should be evaluated to determine whether he meets criteria for temporary detention.

cc: DBHDS Facility Directors and Forensic Coordinators

Community Services Boards Executive Directors and Forensic Coordinators

University of Virginia Institute of Law, Psychiatry, and Public Policy

Virginia Association of Community Services Boards

COMMONWEALTH of VIRGINIA

NELSON SMITH

COMMISSIONER

DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES Post Office Box 1797 Richmond, Virginia 23218-1797 Telephone (804) 786-3921 Fax (804) 371-6638 www.dbhds.virginia.gov

TO:

Forensic Evaluators Approved by DBHDS to Complete Adult Pretrial Evaluations

FROM: Elizabeth Hunt, Ph.D., ABPP

Forensic Evaluation Manager

DBHDS

DATE: November 15, 2023 SUBJECT: Additional Info on SB1507/HB1908 (DBHDS Guidance FOR 06). The 2023 Virginia General Assembly passed SB1507/HB1908, amending Code §§ 19.2-169.1 and 19.2-169.2, modifying SB198 (2022). Changes from SB198 permit, in certain misdemeanor cases when a defendant is incompetent to stand trial, the court to dismiss charges and refer the individual to CSB or behavioral health authority for evaluation to determine temporary detention criteria.

Overview of Changes under SB1507/HB1908 In § 19.2-169.1 (D), the modifications from SB1507/HB1908 are in bold and the code now states that “Upon completion of the evaluation, the evaluators shall promptly submit a report in writing to the court and the attorneys of record concerning (i) the defendant's capacity to understand the proceedings against him; (ii) the defendant's ability to assist his attorney; (iii) the defendant's need for treatment in the event he is found incompetent but restorable, or incompetent for the foreseeable future; and (iv) if the defendant has been charged with a misdemeanor violation of Article 3 (§ 18.2-95 et seq.) of Chapter 5 of Title 18.2 or a misdemeanor violation of § 18.2-119, 18.2-137, 18.2-388, 18.2-415, or 19.2-128, whether the defendant should be evaluated to determine whether he meets the criteria for temporary detention pursuant to § 37.2-809 in the event he is found incompetent but restorable or incompetent for the foreseeable future.” While code language for SB198 indicated that the report “may” recommend that the court direct the CSB to conduct an evaluation to determine whether the defendant meets criteria for temporary detention, SB1507/HB1908 code language now indicates that the report “shall” include whether the defendant should be evaluated to determine whether he meets the criteria for temporary detention. Thus, evaluators are required to include this recommendation in their opinion for applicable cases.

In § 19.2-169.2, the modifications from SB1507/HB1908 apply to sections C and D.

For Section C, the code now states, “Notwithstanding the provisions of subsection A, in cases in which (i) the defendant has been charged with a misdemeanor violation of Article 3 (§ 18.2-95 et Page 2 of 3 Additional Information SB1507/HB1908

seq.) of Chapter 5 of Title 18.2 or a misdemeanor violation of § 18.2-119, 18.2-137, 18.2-388, 18.2-415, or 19.2-128; (ii) the defendant has been found to be incompetent pursuant to subsection E or F of § 19.2-169.1; and (iii) the competency report described in subsection D of § 19.2-169.1 recommends that the defendant be evaluated to determine whether he meets the criteria for temporary detention pursuant to § 37.2-809, the court may order the community services board or behavioral health authority serving the jurisdiction in which the defendant is located to (a) conduct an evaluation of the defendant and (b) if the community services board or behavioral health authority determines that the defendant meets the criteria for temporary detention, file a petition for issuance of an order for temporary detention pursuant to § 37.2-809.

The community services board or behavioral health authority shall notify the court within 72 hours of evaluation completion and, if appropriate, file a petition for temporary detention. The court may dismiss charges without prejudice unless the Commonwealth’s attorney opposes.

In § 19.2-169.2 D, if a defendant refuses or fails to appear for evaluation, the court shall issue a mandatory order and capias for transport. SB1507/HB1908 clarifies steps occur sequentially; charges are not dismissed until the detention petition is filed. Law enforcement transport is now included.

Application to Evaluations: These modifications, effective July 1, 2023, apply to misdemeanor charges of larceny, trespassing, property damage, disorderly conduct, failure to appear, or public intoxication.

Evaluators must include in competency reports whether the defendant should be evaluated for temporary detention when opined incompetent but restorable for the specified misdemeanors. Follow the Code for steps.

Step 1: Formulate competence opinion. Step 2: If incompetent, determine restorability, referencing § 19.2-169.1(D) for unrestorable cases, e.g., irreversible conditions or recent unrestorability.

competency due to irreversible medical condition or recent unrestorability within two years.

If the defendant is likely to remain incompetent (URIST), follow § 19.2-169.3(A) and standard procedures.

Step 3: If incompetent but restorable, review charges.

Unless charges are only listed misdemeanors, recommend restoration type (outpatient/inpatient). Standard procedures apply.

Step 4: For listed misdemeanors, review civil commitment laws and include in report whether defendant should be evaluated for temporary detention, referencing § 19.2-169.1 and § 19.2-169.2.

If your opinion is that the defendant should be evaluated to determine whether he meets criteria for temporary detention, then include a statement in the opinion section of your report that notifies the court that the defendant should be evaluated to determine whether he meets criteria for temporary detention (you may also consider citing § 19.2-169.1 (D) and § 19.2-169.2 (C) and (D)). You should still include recommendations regarding restoration (including whether restoration should occur on an outpatient or inpatient basis) in the event the court does not pursue this option.

• In cases where the defendant should be evaluated for temporary detention, evaluators must ensure safety and notify appropriate entities promptly.

If no detention evaluation is recommended, advise on restoration type (outpatient/inpatient). Standard procedures apply.

Summary: The opinion section must include the following per the referenced code sections:

1. Opinion on defendant's competence or incompetence.
2. Restoration recommendation (outpatient or inpatient).
3. Your recommendation on whether the defendant should be evaluated for temporary detention.

cc: DBHDS Facility Directors and Forensic Coordinators

Community Services Boards Executive Directors and Forensic Coordinators

University of Virginia Institute of Law, Psychiatry, and Public Policy

Virginia Association of Community Services Boards

Discharge Assistance Program Administrative Manual

Commonwealth of Virginia Department of Behavioral Health and Developmental Services

Effective April 1, 2018 Discharge Assistance Program Manual 1 Table of Contents Page

1. Background of the Discharge Assistance Program (DAP) 2
2. Purpose of the DAP 2
3. General Requirements 3
4. DAP Management Structure 3

a. Regional Program Model 3

b. Regional Management Group (RMG) 3

c. Regional Utilization Management and Consultation Team (RUMCT) 4

d. RUMCT Responsibilities 4

e. Department Staff Participation 5

1. DAP Financial Management 5

a. Allocation and Re-allocation of State DAP Funds 5

b. Disbursement of State DAP Funds 6

c. Allowable Uses of State DAP Funds 6

d. Maximizing Other Funding and Revenue Sources 7

e. Unexpended State DAP Funds 7

1. DAP Service Management 8

a. Discharge Readiness 8

b. Extraordinary Barriers to Discharge List Monitoring and Reporting 8

c. Development of Individualized Discharge Assistance Program Plans 8

d. Monitoring of Individualized Discharge Assistance Program Plans 8

e. Rehospitalization 9

1. Transfers of Individuals Among CSBs and Regions 10
2. Reporting 11

a. Performance Contract Reporting Requirements 11

b. Community Consumer Submission 3 (CCS 3) Reporting 11

c. Community Automated Reporting System (CARS) Reporting 12

1. Review and Evaluation 12

a. Regional Utilization Reviews 12

b. Department Reviews 12

c. Performance Measures 12 Appendices A. Definitions 13 B. Model Memorandum of Understanding 15 C. Clinical Readiness for Discharge Rating Scale 30 D. Community Services Performance Contract Exhibit C 31 E. DAP Performance Measures 33 F. Notes and Sources for Performance measures 34 Discharge Assistance Program Administrative Manual 2

1. Background of the Discharge Assistance Program (DAP)

The Department of Behavioral Health and Developmental Services (Department) initiated the Discharge Assistance Program (DAP) in 1998. The DAP supports the Department’s commitment to person-centered and recovery based care and its vision of a system of services and supports driven by individuals receiving services that promotes self-determination, empowerment, recovery, resilience, health, and the highest level of participation by individuals receiving services in all aspects of community life, including work, school, family, and other meaningful relationships. The DAP is supported with a pool of state mental health funds allocated to each DBHDS region (Region) to implement community capacity and/or individualized services and supports that enable adults receiving services in state hospitals to live in the community. The DAP offers a flexible approach for responding to barriers to discharge from state hospitals once an individual has been determined to be clinically ready for discharge.

Community service boards and the behavioral health authority, hereafter referred to as CSBs, through the Regions, use the DAP to support community services and supports that enable individuals to transition from state hospitals to communities where they can recover in the least restrictive and most integrated settings possible.

Regional allocations of DAP state mental health funds are used for individuals at the state hospital whose needs cannot be addressed through the typical array of CSB services and community supports, or if they do not have the funding required to access those services.

Usually these individuals have had long lengths of stay in the hospital and have complex conditions or specialized needs that create barriers to discharge. These barriers often include one or more of the following: ● a forensic legal status; ● absence of guardians or authorized representatives; ● lack of affordable housing with sufficient and reliable services and supports that are necessary to enable independent living; ● challenging behaviors or conditions, including complex psychiatric symptoms or significant behaviors, that are difficult to manage and make it difficult to identify willing providers; or ● complex medical and/or chronic health conditions;

1. Purpose of the DAP

This manual provides CSBs and their associated Regions with the guidelines for use of DAP.

The DAP has three purposes: A. to serve individuals already discharged from state hospitals who are presently receiving services through the DAP and transition them into non-DAP funded services and supports as soon as able;

B. to serve adults in state hospitals who have been determined to be clinically ready for discharge and for whom additional funding for services and supports is required to support their placement in the community through the development, funding, implementation, and utilization review of discharge assistance funds, and

Discharge Assistance Program Administrative Manual 3 C. to fund start-up and/or support ongoing costs for community based services and supports that enable individuals in state hospitals to be discharged to those services.

This manual describes a uniform mechanism for CSBs and Regions to manage, coordinate, and monitor services provided through the expenditure of DAP funds for IDAPPs and to review the effective utilization of DAP services and resources.

1. General Requirements

A. The CSBs and state hospital in each region shall develop a memorandum of understanding (MOU) that outlines the region’s practices, processes, and timelines for ensuring compliance with the requirements in this manual. The MOU shall be consistent with the applicable regional provisions and procedures of the current Core Services Taxonomy. The fiscal agent CSB shall ensure the MOU is available for the Department’s review. A model MOU is contained in Appendix B of this manual.

B. CSBs, regional managers, and the Department shall comply in their implementation of the DAP with all applicable provisions of state and federal laws and regulations and the provisions and requirements of this manual, the current community services performance contract, the Discharge Protocols for Community Services Boards and State Hospitals, the current Human Rights and Licensing Regulations, and applicable State Board policies.

Applicable provisions of the current Community Services Performance Contract (CSPC) include Exhibit C, attached to this manual as Appendix D, Appendix E: Regional Program Operating Principles and Appendix F: Regional Program Procedures that are in the most recent Core Services Taxonomy, available at http://www.dbhds.virginia.gov. If there are any conflicts or inconsistencies between the current CSPC and this manual, the applicable provisions of the CSPC shall control. However, this manual modifies applicable provisions in Appendix F of the current version of the Core Services Taxonomy to reflect the unique nature of the DAP.

C. All participating CSBs, regional managers, state hospitals and the Department shall encrypt transmissions of DAP-related information and data about individuals receiving DAP services, including all forms and reports containing protected health information (PHI) or protected individual information (PII), in a manner specified in the community services performance contract and pursuant to the applicable provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and subsequent implementing regulations.

D. No exceptions or amendments to this manual shall be effective without being reviewed and approved by the Department, dated, and placed in this manual.

1. DAP Management Structure A. Regional Program Model: Participating CSBs shall select a regional program model from Appendix E of the current Core Services Taxonomy for the operation of the regional DAP and reflect this model in the MOU developed pursuant to section 3.a of this manual.

Discharge Assistance Program Administrative Manual 4

B. Regional Management Group (RMG): The participating CSBs and the state hospital serving the region shall establish a RMG. The executive director of each participating CSB and the director of the state hospital shall serve on or appoint one member to the RMG. The RMG shall establish and monitor the operation of a Regional Utilization Management and Consultation Team (RUMCT). The RMG shall:

1. manage the DAP and coordinate the use of funding provided for the DAP, including reallocating state DAP funds among CSBs and working with the Department to reallocate state DAP funds among regions if necessary;
2. assure the effective utilization of the services and resources provided through the DAP; and
3. assure that the guidelines outlined in the manual are consistently applied in the administration of DAP.

The RMG may authorize the employment of a regional manager and the necessary staff to administer the DAP with funds drawn from existing regional resources. The RMG shall identify the job description of all staff and identify which CSB will provide supervision of the regional manager and staff. The establishment and operation of the RMG shall be described in the MOU implemented by the participating CSBs and state hospital. The RMG shall comply with the applicable provisions the Regional Program Operating Principles and the Regional Program Procedures that are in the current Core Services Taxonomy. In many instances, the responsibilities will be carried out by participating CSBs, the participating state hospital, or the regional manager.

C. Regional Utilization Management and Consultation Team (RUMCT): The RUMCT shall consist of representatives from participating CSBs in the region, participating state hospitals, and others as may be appointed by the RMG, such as the regional manager. The positions of the representatives who serve on this team shall be identified in the MOU. Since DAP is only one component of the utilization management functions of the RUMCT, a subcommittee designated by the RUMCT may be given authority to perform the functions described in this section. The RUMCT, through the regional manager and participating CSBs, shall ensure compliance with the documentation required for IDAPP submission and review. The establishment and operation of the RUMCT shall be described in the MOU implemented by the participating CSBs and state hospital. The RUMCT shall comply with the applicable provisions of the Regional Program Operating Principles and the Regional Program Procedures that are in the current Core Services Taxonomy D. RUMCT Responsibilities: The responsibilities of the RUMCT will be carried out by designated representatives of the CSBs and the state hospital serving the region, designated subcommittees, and/or the regional manager. The RUMCT shall:

1. review proposed IDAPPs to assure services correspond to the individuals’ needs and promote appropriate and effective services to assist with maintaining stability in the community.

Discharge Assistance Program Administrative Manual 5

1. jointly conduct utilization reviews of all IDAPPs at least quarterly. Plans will be reviewed monthly or as needed to determine available funding if there are DAP approval requests for which insufficient funds exist
2. the utilization review by the RUMCT will ensure the: a. continued appropriateness of services, b. implementation of approved IDAPPS, including the review of events related to the individual such as re-hospitalization, incarceration relocation, etc. c. ensure accurate financial information is provided by their CSB to the regional managers for quarterly reports d. address reductions in service levels and/or discontinuation of DAP services resulting in available funds. e. This utilization review process may result in revisions of IDAPPS, adjustment to and/or redistribution of DAP funds.
3. review individuals who are clinically ready for discharge, especially individuals who have been on the state hospital Extraordinary Barriers to Discharge List (EBL), to identify or recommend the development of community services and funding appropriate to their clinical needs. The RUMCT will ensure that the RMG is informed of the results of these reviews and subsequent related actions.
4. facilitate, at the request of the case management CSB, resolution of situations that are preventing an individual’s timely discharge from a state hospital or an individual’s continued tenure in the community.
5. identify opportunities for two or more CSBs to work together to develop programs or placements that would permit individuals to be discharged from the state hospital participating in the regional partnership more expeditiously.
6. review and endorse all new IDAPPs (ongoing or one-time). The review and approval process may be conducted in person, by email, or through the use of other technology.
7. Review proposals for use of DAP to increase community capacity prior to submitting to the Department for approval.

As a member of the RUMCT, the regional manager, in collaboration with the participating CSBs, shall maintain a current database on all individuals receiving DAP-funded services.

This database shall include electronic copies of all on-going or one-time IDAPPs. All IDAPPs shall be submitted using the Department approved form. The regional manager shall maintain automated back-up data transferable by encryption on all regional DAP activities.

E. Department Staff Participation: Although not members of RMG or RUMCT, designated Department staff shall have access to all meetings and documents maintained or used by these bodies, as described in the current Community Service Performance Contract. DBHDS staff may attend and participate in all meetings or other related activities of the region.

Discharge Assistance Program Administrative Manual 6

1. DAP Financial Management

A. Allocation and Re-allocation of State DAP Funds: Effective in FY 2015, all mental health DAP funds were designated and distributed as regional funds.

All DAP funds are designated as restricted funds. CSBs must track, account for, and report all of the actual expenditures supported by these funds separately in CARS and DAP reports.

These restricted funds cannot be used for purposes other than DAP. This also applies to unspent prior year balances.

B. Disbursement of State DAP Funds: The Department disburses regional DAP funds directly to the CSB acting as the DAP fiscal agent for the region, as part of the regular semi-monthly CSB payments. The fiscal agent CSB administers these funds and distributes the funds for payment of delivered services and/or as determined by the RMG and as described in the regional MOU.

The CSB acting as the fiscal agent for the region shall receive payments of state funds from the Department for the DAP through its community services performance contract. The fiscal agent CSB for the region must ensure that previously approved IDAPPs continue to be funded first.

Due to the unpredictability of actual DAP expenditures for individual plans, it is expected that regions will maximize ultimate utilization of funds by over allocating during the year and scrubbing existing plans to cover the needs. If a region is unable to identify funds sufficient to cover plans that were approved but above the region’s DAP allocation, DBHDS will assure that funding is provided to cover the DAP shortfall.

C. Allowable Uses of State DAP Funds:

1. DAP funds allocated to regions and disbursed to participating CSBs shall be used for the discharge and community support of individuals for whom IDAPPs have been approved by the RUMCT or for DBHDS approved community infrastructure development or service expansion that directly and measurably facilitates state hospital discharges.
2. DAP funding may be expended for any approved combination of services that assures the needs of individuals with IDAPPs are met in the most integrated and least restrictive community settings.
3. Regions must use DAP funds only to support the costs of approved ongoing or one-time IDAPPs or DBHDS approved community infrastructure development or service expansion that directly and measurably facilitates state hospital discharges. Any other use of DAP funds is not allowed and funds used for other purposes are subject to recovery by the Department.
4. Regions shall prioritize the use DAP funds for individuals who have the greatest tenure on the EBL. However, this requirement is subject to the availability of funds and the overall ability to facilitate discharge.

Discharge Assistance Program Administrative Manual 7

1. Regions may use DAP funds to pay for medications as part of an approved IDAPP only after other sources of support for medications have been exhausted. These sources include state MH Pharmacy-Medication Support funds that are allocated to CSBs, indigent care programs offered by most pharmaceutical manufactures, and Medicaid.

Medicare Part D, the prescription drug benefit, requires true out of pocket costs. DAP funds may not be used on behalf of a Part D beneficiary, (e.g., assistance with copayments). DAP funds do not meet the federal definition of incurred out of pocket costs required by Part D.

1. Regions cannot use DAP funds to serve individuals receiving state-funded PACT, except for direct residential placement costs such as rent or housing subsidies or other non-PACT provided services.
2. Regions cannot use DAP funds for individuals already living in the community who were previously discharged or previously received DAP services but who no longer have an IDAPP authorized by the RUMCT.
3. Regions cannot use DAP funds to support CSB staff positions or other CSB programs or services that are unrelated to specific individual needs as reflected in on-going IDAPPs.

For example, this includes CSB state hospital liaison positions.

1. Regions cannot approve the use of DAP funds as direct income to any individual receiving DAP services. DAP funds are not individual entitlements and cannot be used to provide personal income to individuals receiving DAP services. 10. For individuals served under DAP who are not Medicaid eligible but are receiving State Plan or Clinic Option Services the cost of those services are not to exceed the cost or frequency of those services.

D. Maximizing Other Funding and Revenue Sources: The region must use DAP funds as the funding source of last resort for all IDAPPs. The RMG, RUMCT and the participating CSBs shall ensure that other funds such as Medicaid payments, other appropriate state general funds, fees paid by individuals receiving services, and other third-party funding sources are used to offset the costs of approved IDAPPs to the greatest extent possible so that state DAP funds can be used to discharge the greatest number of individuals from state hospitals. The costs of an IDAPP must be adjusted to reflect other sources of funding or revenues that are identified and obtained. In cases where application was made for benefits to be started/reinstated upon discharge from the hospitals, CSBs will monitor the status of the application monthly. CSBs will inform providers of expectations to back bill Medicaid whenever possible and return any DAP paybacks to the Region and will monitor compliance. This shall be documented in records maintained by the CSB and the regional manager and in reports submitted to the Department.

E. Unexpended State DAP Funds: Generally, the use of unspent DAP funds is governed by Appendix C of the CSB Administrative Requirements, incorporated by reference and agreement of the parties into the current community service performance contract and available on the Office of Support Services page of the Department’s web site at http://www.dbhds.virginia.gov. All DAP funds are restricted. Any DAP funds that remain unspent at the end of the fiscal year in which they were disbursed by the Department shall remain restricted funds. Consequently, those unspent Discharge Assistance Program Administrative Manual 8 DAP funds cannot be used for other purposes and shall be used by regions and participating CSBs to defray the costs of current IDAPPs before current fiscal year state DAP funds are used. Balances of unspent state DAP funds that are not used within the fiscal year in which they were allocated are subject to recovery by the Department through future payments to regional fiscal agent CSB.

During the fiscal year, unexpended DAP funds may accrue as a result of delays in discharges, re-hospitalization or incarceration of an individual receiving DAP services, reductions in services in approved IDAPPs, termination of an IDAPP, and/or changes in allocations among CSBs. The RUMCT, with authorization from the RMG, may approve the use of any of its unexpended DAP funds only for the following priorities:

1. for one-time IDAPPs to support the discharge of individuals in the state hospital;
2. for addressing the one-time needs of individuals with existing IDAPPs;
3. for transitional costs of individuals determined to be NGRI as part of the privileging process or for other individuals in state hospitals with documented clinical needs for transitional services and supports in order to be discharged. This may at times be an exception to the requirement that the individual be ‘ready for discharge’ as advancement through the NGRI privileging process requires trial passes;
4. for temporary funding to supplement an IDAPP while the CSB obtains benefits for an individual;
5. when needed, to cover the cost of obtaining a guardian for an individual in a state hospital. This process may begin prior to the individual becoming clinically ready for discharge in order to prevent the guardianship process from delaying discharge when the individual is clinically ready.
6. in specific cases and with the approval of the RUMCT, large one-time fund IDAPPS may be granted to individuals requiring on-going supports when on-going DAP dollars are not available at the time of discharge. In those cases, there is no time limitation on the one-time support. However, these individuals must be reported in CCS3 and be given a 910 Code designation.
7. for developing and/or expanding regional infrastructure to enable the discharge of individuals in state hospitals, such as residential resources or other community placements. When DAP funds are used to create community capacity, the specific use of the funds, the individuals discharged and services provided as a result of the infrastructure will be reported annually along with the year-end IDAPP report to

DBHDS.

If a region is not able to expend at least 90 percent of its total on-going regional DAP allocation for active on-going plans and obligate at least 95 percent of its total regional state DAP funding allocation by the end of the fiscal year, the Department will work with the RMG to transfer unspent or unobligated state DAP funds to other regions to reduce the EBL at other state hospitals unless the Department determines that there are extenuating circumstances which justify an exception.

Discharge Assistance Program Administrative Manual 9

1. Census Management A. Discharge Readiness: Participating CSBs shall develop the discharge plan in consultation with the individual, guardian or authorized representative, and the state hospital treatment team. This plan describes the specific community mental health, developmental, substance abuse, employment, health, educational, housing, recreation, transportation, legal, and advocacy services and supports needed by the individual following an episode of hospitalization and identifies the providers that have agreed to provide these services to the individual.

B. Clinically Ready for Discharge Monitoring: The participating CSBs through the RUMCT and regional manager shall monitor individuals who are clinically ready for discharge at the state hospital serving the region monthly to track individuals for whom they are the case management CSB and ensure the individuals are discharged as soon as possible.

C. Development of Individualized Discharge Assistance Program Plans:

1. The case management CSB, the individual being discharged, his/her guardian or authorized representative, and the state hospital treatment team shall determine the most appropriate services and placement in the community for the individual that are consistent with his or her choices to the greatest extent possible.
2. DAP services and supports must be documented on the IDAPP, and the IDAPP must be consistent with the individual’s preferences and choices to the greatest extent possible.
3. All individuals with on-going IDAPPs must receive case management services or documented CSB monitoring. This shall be documented monthly in progress notes by the case management CSB and used to provide updates during regional DAP scrubbings.
4. The IDAPP shall be completed and endorsed by all relevant parties. The case management CSB must submit a brief narrative describing the individual needs and proposed plan, identified placement, projected discharge date, and an explanation of all revenues and costs with all new or renewing IDAPPs. The explanation of costs shall include a justification/explanation as to why DAP is a last-resort funding source, particularly for individuals who have Medicaid/Medicare, or will become eligible for these benefits upon discharge. New IDAPPs must identify all the services the individual needs to successfully transition to the community, the providers who have agreed to provide the services, and a projected discharge date. The IDAPP must display all of the revenues by source and all of the projected expenses for the services in the IDAPP.

D. Monitoring of IDAPPs: The RUMCT or its designee shall review at least quarterly the implementation of all IDAPPs to ensure the effective and efficient utilization of the DAP funds. If the region does not have sufficient funds to approve new ongoing DAP requests, the review of existing plans shall occur monthly, or more often if needed. The RUMCT shall develop a process of communication to ensure that the RMG is informed of the utilization review activities.

If the case management CSB is not able to implement an approved IDAPP for the individual within 30 calendar days of his or her projected date of discharge, one of the following actions shall be taken within 30 calendar days following the projected date of discharge: Discharge Assistance Program Administrative Manual 10

1. The region shall identify and discharge another individual who is on the EBL or who has been determined to be clinically ready for discharge and for whom DAP funding is appropriate for addressing the barriers to that individual’s discharge;

If the preceding action does not occur within 30 days, the funds identified for the IDAPP will revert to the RUMCT for an IDAPP to discharge an individual from another region on the EBL (according to prioritization process in C.4.) and for whom DAP funding is appropriate for addressing the barriers to that individual’s discharge;

1. Should an individual who has been adjudicated Not Guilty by Reason of Insanity (NGRI) not be discharged within 30 days of the projected discharge date due to circumstances beyond the control of the individual, CSB and/or state hospital; the CSB shall send a memo to the RUMCT with an explanation of said circumstance.

Examples of these circumstance could include, but not limited to: IFPC and/or FRP revision requests, residential provider withdrawing acceptance for reasons not related to the individual’s behavior, the NGRI court’s delay in scheduling a conditional release hearing date, etc. The RUMCT shall make a decision to continue funding IDAPP based on the facts presented.

E. Rehospitalization: Upon occasion it may be necessary for DAP enrollees to receive in-patient psychiatric services or be incarcerated. Should this occur, the case management CSB will notify the RUMCT. The RUMCT then may select from the following options:

1. If the RUMCT approves a written request from the CSB, it will stop current payments and resume payments upon the individual’s discharge, if that date is within an agreed upon number of days not to exceed 90 days from the date of re-hospitalization in a state hospital;
2. If the CSB submits a request to the RUMCT that states re-hospitalization will exceed 30 days and on-going funds will be needed to maintain the individual’s residence for an agreed upon period not to exceed 90 days, the RUMCT may approve the provision of the necessary funds during that period only in the amount required to maintain the individual’s place of residence. The RMG shall redistribute any resulting unspent funds in accordance with the provisions in this manual; or
3. The CSB returns the state DAP funds, less year-to-date expenditures, for the unimplemented IDAPP to the RUMCT for redistribution.

Note: The cost of supporting a substitute individual shall not exceed the amount requested in the originally approved IDAPP unless funding is available and approved by the RUMCT.

Should the cost of services be less than originally requested, unexpended funds will be available to the RUMCT for redistribution in accordance with the provisions of this manual.

For all IDAPPs where the service provider is not the CSB, the CSB shall develop a purchase of service agreement, memorandum of agreement, or other instrument consistent with the CSBs’ purchasing policies and procedures. All such instruments shall be maintained by the affected CSBs and available to the Department upon request.

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1. Transfers of Individuals Between CSBs or Regions (These instructions apply unless the Department determines that there are extenuating circumstances which justify an exception) A. In the case of individuals transferring between CSBs, the CSB in the chosen locality becomes the receiving case management CSB and works with the original case management CSB, the individual, and the state hospital to effect a smooth discharge and transition to the community. The case management CSB of origin is responsible for the completion of the discharge plan, and shall collaborate with the receiving CSB. Effective July 1, 2018 DAP funds will be transferred from the originating/home CSB to the receiving CSB within 6 months of the individual’s transition.

B. The receiving region accepts the transfer of the IDAPP funds. The receiving CSB shall then be responsible for the reporting required by the performance contract. The affected CSBs and regions shall notify the respective regional managers and the Department of any changes in case management CSB designation and request the fund transfer no later than 30 days post discharge or transfer.

C. If additional DAP funds other than those provided through the original IDAPP are required to support the individual in the new setting after transfer, the region holding the IDAPP funds for the individual shall provide the additional funding based on approval of a revised IDAPP.

D. If an individual receiving DAP services decides to move to another CSB’s service area within the region, the receiving CSB will assume Case Management CSB responsibilities and shall be responsible for the appropriate reporting in CARS and CCS 3.

E. If an individual approved for DAP funds elects to reside outside of their DBHDS region of origin, it is understood that the respective regions and CSBs shall work collaboratively in addressing the individual’s preferences and needs.

F. Individuals who have been adjudicated NGRI and are placed outside of their case management CSB service area or region may have specific conditions associated with their Conditional Release Plan related to, their case management CSB or their area of residence.

Under these conditions, the CSB may choose (or be required) not to reallocate funds and oversight to the new region, in which case the CSB and region of origin shall remain the case management CSB and region of record. The case management CSB is then responsible for all required reporting under the performance contract and conditional release plan.

Resolution process:

A. When disagreements related to transfer of DAP oversight occur, the regional utilization management teams shall make a reasonable effort to resolve the areas of disagreement. If they are unable to come to a resolution, then the regional managers shall notify their respective regional CSB Regional Chair of their disagreement with the transfer request.

Discharge Assistance Program Administrative Manual 12 B. The regional chairs shall make every attempt to resolve the issues that prevent agreement about transfer of the DAP.

C. If the disagreement remains unresolved, the regional managers shall within two weeks of the CSB chairs’ meeting, initiate a request in writing to the Director of Acute Care (or designee) for dispute resolution.

D. The Director of Acute Care (or designee) shall gather and review the information and consult with the relevant parties to come to a decision regarding the transfer of DAP oversight.

E. During the process outlined above, the individual’s placement and services shall not be delayed. The resolution process will simply address regional “ownership” of the DAP funds and case management CSB designation.

1. Reporting A. Performance Contract Reporting Requirements: Participating CSBs and regional managers shall comply with all of the requirements in Exhibit C of the community services performance contract, contained in this manual as Appendix D, including the following reporting requirements.

The regional manager shall submit the quarterly summary of IDAPPs to the Department in a format reviewed by the Department in consultation with regional managers and designated members of VACSB. Quarterly reports will document year-to-date information about ongoing and one-time IDAPPs, including data about each individual receiving DAP services, the amounts of DAP funds approved for each IDAPP, the total number of IDAPPs that have been implemented, and the total DAP funds obligated for these IDAPPs. The first and third quarter reports are due thirty (30) days following the end of the quarter. The second and fourth quarter reports are due forty-five (45) days after the end of the quarter. It is the participating CSB’s responsibility to provide the regional manager with accurate information related to actual costs and other data to ensure the accuracy of reports. Reports on DAP funding that is used to increase community capacity will be due at the end of each fiscal year, or as otherwise required by DBHDS.

B. Community Consumer Submission 3 (CCS 3) Reporting:

The case management CSB is responsible for ensuring that the required information about the individual, his/her type of care (Consumer Designation Code for DAP) and the services received are entered in their information system and reported to the Department through the extraction by the CCS 3. CCS 3 submissions must satisfy the requirements in Exhibit I of the performance contract. These requirements apply to all IDAPPs implemented with DAP funds.

CSBs shall assign a 910 Consumer Designation Code only to individuals with ongoing IDAPPs, including those funded through extended use of onetime funds. Additional information about assigning, initiating, and ending consumer designation codes and about all other aspects of reporting data through the CCS is available in the current Community Discharge Assistance Program Administrative Manual 13 Consumer Submission 3 Extract Specifications, which is available at http://www.dbhds.virginia.gov/professionals-and-service-providers/office-of-support-services C. Community Automated Reporting System (CARS) Reporting: The case management CSB responsible for directly providing or purchasing the services in an individual’s IDAPP shall reflect, account for, and report the actual revenues and actual expenses associated with the services in the IDAPP through the mid-year and end of the fiscal year CARS reports. Reports must satisfy the requirements in Exhibit I of the performance contract. These requirements apply to all IDAPPs implemented with DAP funds.

1. Reviews and Evaluation A. Utilization Review: The participating CSBs and state hospital in each region shall develop and implement a utilization review process for all IDAPPs. At a minimum, this process (known as “scrubbing”) will include a review of the current IDAPPs, services being received, confirmation that the individual has applied for and/or is receiving all eligible benefits or entitlements (e.g., Medicaid, insurance, SSI/SSDI, or other sources), amounts of other income received, and confirmation of the residential placement during the quarter.

The RUMCT and/or designated subcommittee shall conduct quarterly utilization reviews of approved IDAPPs to ensure continued appropriateness of services, compliance with approved IDAPPs and individual-related events such as re-hospitalizations, incarcerations, or terminations of services.

If the region does not have sufficient unallocated DAP funds to support approval requests for new plans, the RUMCT will review existing plans monthly, or more frequently as needed, to identify under or unused funds.

B. Department Review: The Department shall regularly monitor the performance of the regions’ management of the DAP as well as the CSBs’ implementation of IDDAPs. Pursuant to sections 6.f and 7.c in the CSPC, the Department may conduct on-going utilization reviews and analyze information about individuals receiving services, the services they received, and financial information related to the DAP, such as re-hospitalizations, transitions to non-DAP supported services and supports, maximization of other revenue sources, expenditure patterns, use of resources, outcomes, and performance measures to ensure the continued effectiveness and efficiency of the DAP.

The Department shall include the financial and programmatic operations of the DAP as part of its regular CSB Review, which is conducted by multidisciplinary teams including Department fiscal and program staff. CSBs are identified for review through standard risk management criteria.

Discharge Assistance Program Administrative Manual 14 C. Performance Measures: The Department has developed performance measures for the DAP to assess the effectiveness of the DAP. These measures use existing data sources to avoid imposing additional workload burdens on CSBs, state facilities, and regional managers. The current set of measures is contained in Appendix E of this manual. The RUMCT and RMG shall monitor the performance measures established by the Department through reports provided by the Department. The RMG and participating CSBs shall take action in a timely manner to address unsatisfactory performance on any measure.

Discharge Assistance Program Administrative Manual 15 Appendix A: Definitions

Case Management Community Services Board (CSB) means the CSB that serves the area in which an adult resides. The case management CSB is responsible for case management, liaison with the state hospital when an individual is admitted, and discharge planning. Reference in this manual to CSB means case management CSB, unless the context clearly indicates otherwise, and CSB includes the behavioral health authority established pursuant to § 37.2-601of the Code of Virginia. CSB and BHA are defined in § 37.2-100 of the Code of Virginia.

Community Automated Reporting System (CARS) means the Department software application that each CSB uses to report the types and capacities of services provided, costs for services provided, and revenues received by source and amount and expenses paid by program area (mental health, developmental, or substance abuse services) and for emergency and ancillary services. CSBs submit CARS reports to the Department mid-year and at the end of the fiscal year.

Community Consumer Submission 3 (CCS 3) means the Department software application that each CSB uses to report data on individuals receiving mental health, developmental, substance abuse, emergency and ancillary services and the types and amounts of services they receive.

CSBs submit CCS 3 extracts to the Department monthly.

Clinical Readiness for Discharge means the determination that an individual is clinically ready for discharge from a state hospital. All state hospitals and CSBs make this determination consistently using the standard clinical readiness for discharge rating scale established by the Department. The rating scale is contained in Appendix C.

Discharge plan means an individualized plan for post-hospital services that is developed by the CSB in consultation with the individual, guardian or authorized representative if one has been appointed or designated or if one is needed, and the state hospital treatment team. This plan is required by § 37.2-505 or § 37.2-608 of the Code of Virginia, and it describes the specific community mental health, developmental, substance abuse, employment, health, educational, housing, recreation, transportation, legal, and advocacy services and supports needed by the individual following an episode of hospitalization and identifies the providers that have agreed to provide these services and supports.

Extraordinary Barriers List (EBL) means the list generated by the Department and state hospitals that identifies adults who have been determined to be clinically ready for discharge (rated Level 1), but who remain in the hospital for more than 14 days after that determination.

Individualized Discharge Assistance Program Plan (IDAPP) means the plan developed by the case management CSB and reviewed and approved by the RUMCT that contains all of the services and supports an individual needs to be discharged from a state hospital and identifies the types and amounts of and all of the revenues and costs for those services.

On-going DAP Request means an IDAPP for services and/or supports to be provided on an ongoing basis to the individual.

Discharge Assistance Program Administrative Manual 16 One-time DAP Request means an IDAPP for services and/or supports to be provided to an individual on a time-limited basis. One time DAP requests are not renewable.

Performance Contract means the contract between the Department and a CSB that defines the responsibilities of and requirements on each party for delivery of services, reporting data about individuals receiving services and the services they receive, service quality, performance and outcome measures, and programmatic and fiscal accountability. The contract is the primary accountability mechanism between the Department and CSBs.

DBHDS Region (Region) means the grouping of CSBs and state hospital designated by the Department to address challenges, service needs, and collaborative planning and implementation of initiatives in a defined geographical area congruent with the state hospital’s service area.

Regional participants include representatives from the CSBs, state hospital, private psychiatric hospitals and other private providers, individuals receiving services, family members, advocates, and other stakeholders from within that region.

Regional Management Group (RMG) means the group established in a DBHDS region by the participating CSBs and state hospital that oversees the management of regional programs and the use of regional resources, including state funds. The RMG consists of the executive director of each CSB and the region’s state hospital director.

Regional Utilization Management and Consultation Team (RUMCT), also referred to as Regional Utilization Management (RUM) in some documents, means the group that provides direct oversight and monitoring of the DAP, including development and approval of IDAPPS, DAP planning, funding decisions and the maximization of all revenue sources, utilization management, and the efficient discharge of individuals from state hospitals. The RUMCT includes representatives of the participating CSBs and state hospital and involved private providers. This team also is responsible for monitoring the use of other regional funds or programs, such as LIPOS or crisis stabilization. While not members of the RUMCT, Department central office staff frequently participates in RUMCT meetings.

State Hospital means a mental health hospital operated by the Department of Behavioral Health and Developmental Services. For purpose of this manual, state hospital does not include the Hiram Davis Medical Center, the Commonwealth Center for Children and Adolescents, or the Virginia Center for Behavioral Rehabilitation.

Utilization Review (also known as “scrubbing”) means the process in which the RUMCT reviews active IDAPPs and adjusts services, costs, and revenues to more accurately reflect the changing needs of supporting the individual in the community. While individual needs change and IDAPP expenses may be more or less than the initial projection, these reviews often result in the identification of unneeded funds that may be used for IDAPPs to support discharges of other individuals from state hospitals.

Discharge Assistance Program Administrative Manual 17 Appendix B: Model Memorandum of Understanding

Planning Partnership Region (insert number) CSBs and (insert name) State Hospital Discharge Assistance Program Memorandum of Understanding for FY (insert year)

This Memorandum of Understanding (MOU) is made and entered into on (insert month, day, and year) by and between the community services boards, hereafter referred to as participating CSBs, and the state hospital, hereafter referred to as the participating State Hospital, listed below that are the parties to this MOU.

• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating State Hospital

I. Purpose

The parties listed above enter into this MOU for the purpose of implementing the regional Discharge Assistance Program, hereafter referred to as the DAP. The DAP has three purposes:

• to serve individuals already discharged from state hospitals who are presently receiving services through the DAP and transition them into non-DAP funded services and supports; and
• to serve adults in state hospitals who have been determined to be clinically ready for discharge and for whom additional funding for services and supports is required to support their placement in the community through the development, funding, implementation, and utilization review of discharge assistance funds. .
• to fund start-up and/or support ongoing costs for community based services and supports that enable individuals in state hospitals to be discharged to those services.

This MOU provides a uniform mechanism for the parties to manage, coordinate, and monitor services provided through the expenditure of DAP funds for IDAPPs and to review the effective utilization of DAP services and resources.

Discharge Assistance Program Administrative Manual 18 II. Scope of Work

A. Regional Management Group (RMG)

1. The participating CSBs and the participating State Hospital hereby establish a Regional Management Group, hereafter referred to as the RMG. The Executive Director of each participating CSB and the Director of the participating State Hospital shall each serve on or appoint one member of the RMG. The responsibilities of the RMG may be carried out by participating CSBs, the participating State Hospital, and/or the regional manager and support staff

1. Participating CSBs and the participating State Hospital, through the RMG, shall a. select a regional program model in Appendix E of the current Core Services Taxonomy for the operation of the DAP, b. describe in this MOU how the selected model will operate, and c. comply with the applicable provisions of Appendix E: Regional Program Operating Principles and Appendix F: Regional Program Procedures in the current Core Service Taxonomy.
2. The RMG shall manage the DAP and coordinate the use of funding provided for the DAP, including allocating state DAP funds among CSBs.

1. The RMG shall establish and monitor the operations of the Regional Utilization Management and Consultation Team (RUMCT) to manage all aspects of the DAP.

1. The RMG may authorize the employment of a regional manager and the necessary staff to administer the DAP with funds drawn from existing regional resources. The RMG shall identify the job description of all staff and identify which CSB will provide supervision of the regional manager and staff.

1. The RMG shall coordinate and monitor the effective utilization of the services and resources provided through the DAP using data and reports provided by the RUMCT and regional manager.

1. The RMG shall perform other duties identified in this MOU or assigned by the participating CSBs or participating State Hospital.

1. Although not members of the RMG, designated staff in the Central Office of the Department of Behavioral Health and Developmental Services (Department) shall have access to all documents including IDAPPs maintained or used by the RMG pursuant to applicable provisions of the current community services performance contract and may attend and participate in all meetings or other activities of the RMG.

Discharge Assistance Program Administrative Manual 19 B. Regional Utilization Management and Consultation Team (RUMCT) The RMG shall establish a Regional Utilization Management and Consultation Team, hereafter referred to as the RUMCT, to manage all aspects of the DAP. The RUMCT shall ensure compliance with the requirements outlined in the DAP Administrative Manual and IDAPP submission and review.

The RUMCT shall consist of representatives from participating CSBs in the region, the participating State Hospital, and others as may be appointed by the RMG, such as the regional manager. The RUMCT shall be composed of:

• (insert name, title/position, and organization, e.g., name of CSB)
• (insert name, title/position, and organization, e.g., name of CSB)
• (insert name, title/position, and organization, e.g., name of CSB)
• (insert name, title/position, and organization, e.g., name of CSB)
• (insert name, title/position, and organization, e.g., name of CSB)
• (insert name, title/position, and organization, e.g., name of CSB)
• (insert name, title/position, and organization, e.g., name of CSB)

The RUMCT shall meet at least monthly or more frequently when necessary, for example, depending upon funding needs, census issues or the number of cases to be reviewed. Minutes shall be recorded at each meeting The RUMCT shall:

1. review the proposal of the IDAPPs developed through the DAP to ensure that the services are the most appropriate, effective, and efficient services that meet the clinical needs of the individual receiving services.
2. jointly conduct utilization reviews (“scrubbing”) of all IDAPPs quarterly, or if indicated, more frequently to ensure the: a. continued appropriateness of services, b. implementation of approved IDAPPS, including the review of events related to the individual such as re-hospitalization, incarceration relocation, etc. c. ensure accurate financial information is provided by their CSB to the regional managers for quarterly reports d. address reductions in service levels and/or discontinuation of DAP services resulting in available funds.
3. review individuals who are on the state hospital Extraordinary Barriers to Discharge List (EBL) to identify or recommend the development of community services and funding appropriate to their clinical needs. The RUMCT will ensure that the RMG is informed of the results of these reviews and subsequent related actions.
4. facilitate, at the request of the case management CSB, resolution of individual situations that are preventing an individual’s timely discharge from a state hospital or an individual’s continued tenure in the community.

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1. identify opportunities for two or more CSBs to work together to develop programs or placements that would permit individuals to be discharged from the state hospital participating in the regional partnership more expeditiously.
2. review and endorse (if appropriate) all new IDAPPs (ongoing or one-time). The review and approval process may be conducted in person, by email, or through the use of other technology.

This utilization review process may result in revisions of IDAPPS, adjustment to and/or redistribution of DAP funds.

The regional manager, in collaboration with the participating CSBs, shall maintain a current database on all individuals receiving DAP-funded services. This database shall include electronic copies of all on-going or one-time IDAPPs. All IDAPPs shall be submitted using the Department approved form. The regional manager shall maintain automated back-up data transferable by encryption on all regional DAP activities.

Although not members of the RUMCT, designated staff in the Central Office of the Department shall have access to all documents including IDAPPs maintained or used by the RUMCT pursuant to applicable provisions of the current community services performance and may attend and participate in all meetings or other activities of the

RUMCT.

III. DAP Financial Management (Modify this section and insert applicable details of the financial management operations of the regional program model selected by the RMG.)

A. Allocation and Re-allocation of State DAP Funds

1. The Department allocates all mental health DAP funds on a regional basis among the DBHDS Regions. DAP funds previously designated as local DAP funds and allocated to individual CSBs are now included in the regional state DAP funds.

1. Additionally all DAP funds are designated as restricted funds. CSBs must track, account for, and report all of the actual expenditures supported by these funds separately in CARS and DAP reports. These restricted funds cannot be used for purposes other than DAP.

B. Disbursement of State DAP Funds The Department disburses regional DAP funds directly to the CSB acting as the fiscal agent for the region, as part of the regular semi-monthly CSB payments. The fiscal agent CSB administers these funds and distributes the funds for payment of delivered services and/or as determined by the RMG and as described in the regional MOU.

The CSB acting as the fiscal agent for the region shall receive payments of state funds from the Department for the DAP through its community services performance contract.

The fiscal agent CSB for the region must provide CSBs with sufficient funding to ensure the previously approved IDAPPs continue to be funded.

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C. Allowable Uses of State DAP Funds

1. DAP funds allocated to regions and disbursed to participating CSBs shall be used exclusively for the following purposes: a. to serve individuals already discharged from state hospitals who are presently receiving services through the DAP and transition them, when possible, into non-DAP funded services and supports; and b. to serve adults in state hospitals who have been determined to be clinically ready for discharge and for whom additional funding for services and supports is required to support their placement in the community through the utilization of discharge assistance funds. . c. to fund start-up and/or support ongoing costs for community based services and supports that enable individuals in state hospitals to be discharged to those services.

1. DAP funds may be used (when no other funding sources are available) for any approved services that assure the needs of individuals with approved IDAPPs are met in the most integrated and least restrictive community settings.

1. Regions and participating CSBs typically use DAP funds to support the costs of approved ongoing or one-time IDAPPs. Use of DAP funds to create or expand community infrastructure in order to facilitate state hospital discharges requires prior approval from DBHDS

1. Regions shall prioritize the use DAP funds for individuals who have the greatest tenure on the EBL. However, this requirement is subject to the availability of funds and the overall ability to facilitate discharge.

1. Regions may use DAP funds to pay for medications as part of an approved IDAPP once other sources of support for medications have been exhausted. These sources include mental health state funds previously used for the Department’s community resource pharmacy and now allocated to CSBs for the same purpose, indigent care programs offered by most pharmaceutical manufactures, and Medicaid. Medicare Part D, the prescription drug benefit, requires true out of pocket costs. DAP funds may not be used on behalf of a Part D beneficiary, (e.g., assistance with copayments).

DAP funds do not meet the federal definition of incurred out of pocket costs required by Part D.

1. Regions cannot use DAP funds to serve individuals receiving state-funded PACT, except for direct residential placement costs such as rent or housing subsidies or other non-PACT provided services.

1. Regions cannot use DAP funds for individuals already living in the community who were previously discharged or previously received DAP services but who no longer have an IDAPP authorized by the RUMCT.

Discharge Assistance Program Administrative Manual 22

1. Regions cannot use DAP funds to support CSB staff positions or other CSB programs or services that are unrelated to specific individual needs as reflected in on-going IDAPPs. For example, this includes CSB state hospital liaison positions.

1. Regions cannot approve the use of DAP funds as direct income to any individual receiving DAP services. DAP funds are not individual entitlements and cannot be used to provide personal income to individuals receiving DAP services.

10. For individuals served under DAP who are not Medicaid eligible but are receiving State Plan or Clinic Option Services the cost of those services are not to exceed the cost or frequency of those services.

D. Maximizing Other Funding and Revenue Sources: The region and participating CSBs must use DAP funds as the funding source of last resort for all IDAPPs. The RMG, RUMCT and the participating CSBs shall ensure that other funds such as Medicaid payments, other appropriate state general funds, fees paid by individuals receiving services, and other third-party funding sources are used to offset the costs of approved IDAPPs to the greatest extent possible so that state DAP funds can be used to discharge the greatest number of individuals from state hospitals. The costs of an IDAPP must be adjusted to reflect other sources of funding or revenues that are identified and obtained. This shall be documented in records maintained by the CSB and the regional manager and in reports submitted to the Department.

E. Unexpended State DAP Funds

1. Generally, the use of unspent DAP funds is governed by Appendix C of the CSB Administrative Requirements. However, all DAP funds are restricted and any DAP funds that remain unspent at the end of the fiscal year in which they were disbursed by the Department shall remain restricted funds. Consequently, those unspent DAP funds cannot be used for other purposes and shall be used by region and participating CSBs to defray the costs of current IDAPPs before current fiscal year state DAP funds are used. Unspent balances above 10% of the annual allocation of state DAP funds that are not used within the fiscal year in which they were allocated are subject to recovery by the Department through payments to the Department by the region holding the balances, reductions in current disbursements to the region holding the balances, or reductions in allocations of DAP funds to the region (unless the Department determines that there are extenuating circumstances which justify an exception).

1. The RMG may approve the use of any of its unexpended DAP fund allocations during the current fiscal year that resulted from delays in discharges, re-hospitalization or incarceration of an individual receiving DAP services, reductions in services in approved IDAPPs, termination of an IDAPP, changes in allocations among CSBs, or other balances including year-end balances from previous fiscal years. Unexpended allocations and balances (“onetime funds”) shall be used for the following priorities: Discharge Assistance Program Administrative Manual 23 a. for one-time IDAPPs to support the discharge of individuals on the state hospital EBL; b. for addressing the one-time needs of individuals with approved IDAPPs; c. for transitional costs of individuals determined to be NGRI as part of the privileging process (these individuals might not be rated clinically ready for discharge due to their privileging level, but may need DAP funds to support community passes as part of the process) or for other individuals in state hospitals with documented clinical needs for transitional services and supports in order to be discharged; d. when needed, to cover the cost of obtaining a guardian for an individual in a state hospital. This process may begin prior to the individual becoming clinically ready for discharge e. for temporary funding to supplement an IDAPP while the CSB obtains benefits for an individual; or f. for developing regional infrastructure to enable the discharge of individuals in state hospitals, such as residential resources or other community placements.
2. If a region is not able to expend at least 90 percent of its total on-going regional DAP allocation for active on-going plans and obligate at least 95 percent of its total regional state DAP funding allocation by the end of the fiscal year, the Department will work with the RMG to transfer unspent or unobligated state DAP funds to other regions to reduce the EBL at other state hospitals unless the Department determines that there are extenuating circumstances which justify an exception..

IV. Census Management (Modify this section and insert applicable details in this section of the service management operations of the regional program model selected by the RMG.)

A. Discharge Planning: Participating CSBs shall develop the discharge plan in consultation with the individual, guardian or authorized representative, and the state hospital treatment team. This plan describes the specific community mental health, developmental, or substance abuse, employment, health, educational, housing, recreation, transportation, legal, and advocacy services and supports needed by the individual following an episode of hospitalization and identifies the providers that have agreed to provide these services to the individual.

B. Extraordinary Barriers to Discharge List (EBL) Monitoring and Reporting: The participating CSBs through the RUMCT and regional manager shall monitor the EBL and the Discharge Ready list at the state hospital serving the region monthly to track individuals for whom they are the case management CSBs to ensure the individuals are discharged as soon as possible.

Discharge Assistance Program Administrative Manual 24

C. Development of Individualized Discharge Assistance Program Plans (IDAPP):

1. The case management CSB, the individual being discharged, his/her guardian or authorized representative, and the state hospital treatment team shall determine the most appropriate services and placement in the community for the individual that are consistent with his or her choices to the greatest extent possible.
2. DAP services and supports must be documented on the IDAPP, and the IDAPP must be consistent with the individual’s preferences and choices to the greatest extent possible.
3. All individuals with on-going IDAPPs must receive case management services or documented CSB monitoring. This shall be documented monthly in progress notes by the case management CSB and used to provide updates during DAP “scrubbing”.
4. The IDAPP shall be completed and endorsed by all relevant parties. The case management CSB must submit a brief narrative describing the individual needs and proposed plan, identified placement, projected discharge date, and an explanation of all revenues and costs with all new or renewing IDAPPs. New IDAPPs must identify all the services the individual needs to successfully transition to the community, the providers who have agreed to provide the services, and a projected discharge date.

The IDAPP must display all of the revenues by source and all of the projected expenses for the services in the IDAPP.

1. When DAP funds are used to create or expand community infrastructure, the planned use, costs, services/supports and number of individuals to be served must be submitted to DBHDS for prior approval. The regional manager shall then submit an accounting of expenditures, units/types of service provided and individuals served at the end of each fiscal year.

D. Monitoring of IDAPPs: The RUMCT or its designee shall review at least quarterly and more frequently when there is a shortage of regional DAP funds, the implementation of all IDAPPs to ensure the effective and efficient utilization of the DAP funds. The RUMCT shall develop a process of communication to ensure that the RMG is informed of the utilization review activities.

If the case management CSB is not able to implement an approved IDAPP for the individual within 30 calendar days of his or her projected date of discharge, one of the following actions shall be taken within 30 calendar days following the projected date of discharge:

1. The region shall identify and discharge another individual who is on the EBL or who has been determined to be clinically ready for discharge and for whom DAP funding is appropriate for addressing the barriers to that individual’s discharge;
2. If the preceding action does not occur within 30 days, the funds identified for the IDAPP will revert to the RUMCT for an IDAPP to discharge another individual according to the DAP prioritization process;

Discharge Assistance Program Administrative Manual 25

1. Should an individual who has been adjudicated Not Guilty by Reason of Insanity (NGRI) not be discharged within 30 days of the projected discharge date due to circumstances beyond the control of the individual, CSB and/or state hospital; the CSB shall send a memo to the RUMCT with an explanation of said circumstance.

Examples of these circumstance could include, but not limited to: IFPC and/or FRP revision requests, residential provider withdrawing acceptance for reasons not related to the individual’s behavior, the NGRI court’s delay in scheduling a conditional release hearing date, etc. The RUMCT shall make a decision whether to continue funding IDAPP based on the facts presented.

E. Rehospitalization: Upon occasion it may be necessary for DAP enrollees to receive in-patient psychiatric services or be incarcerated. Should this occur, the case management CSB will notify the RUMCT. The RUMCT then may select from the following options:

1. If the RUMCT approves a written request from the CSB, it will stop current payments and resume payments upon the individual’s discharge, if that date is within an agreed upon number of days not to exceed 90 days from the date of re-hospitalization in a state hospital;
2. If the CSB submits a request to the RUMCT that states re-hospitalization will exceed 30 days and on-going funds will be needed to maintain the individual’s residence for an agreed upon period not to exceed 90 days, the RUMCT may approve the provision of the necessary funds during that period in the amount required to maintain the individual’s place of residence and other critical special services such as maintaining guardianship. The RMG shall redistribute any resulting unspent funds in accordance with the provisions in this manual; or
3. The CSB returns the state DAP funds, less year-to-date expenditures, for the unimplemented IDAPP to the RUMCT for redistribution.

Note: The cost of supporting a substitute individual shall not exceed the amount requested in the originally approved IDAPP unless funding is available and approved by the RUMCT.

Should the cost of services be less than originally requested, unexpended funds will be available to the RUMCT for redistribution in accordance with the provisions of this manual.

For all IDAPPs where the service provider is not the CSB of origin, that CSB shall develop a purchase of service agreement, memorandum of agreement, or other instrument consistent with the CSBs’ purchasing policies and procedures. All such instruments shall be maintained by the affected CSBs and available to the Department upon request.

V. Transfers of Individuals Between CSBs or Regions (Modify this section and insert applicable details in this section of the operations of the regional program model selected by the RMG.) If the individual, or with the consent of a guardian or an authorized representative, chooses to reside in a different locality after discharge from the state hospital, the CSB in the chosen locality becomes the receiving case management CSB and works with the original case management CSB, the individual, and the state hospital to effect a smooth discharge and Discharge Assistance Program Administrative Manual 26 transition to the community. The case management CSB of origin is responsible for the completion of the discharge plan and is expected to collaborate with the receiving CSB.

If an individual receiving DAP services decides to move to another CSB’s service area within the region, the receiving CSB will assume Case Management CSB responsibilities and shall be responsible for the appropriate reporting in CARS and CCS 3.

If an individual approved for DAP funds elects to reside outside of the DBHDS region of origin, it is understood that the respective regions and CSBs shall work collaboratively in addressing the individual’s preferences and needs. The following are examples of how this process applies: The receiving Region accepts the transfer of the IDAPP funds and assumes case management CSB responsibilities. Effective July 1, 2018, the transfer of DAP funds shall occur within six months of the individual being placed in the receiving Region. The receiving CSB shall then be responsible for the reporting required of the performance contract. The affected CSBs and regions shall notify the respective regional managers and the Department of any changes in case management CSB designation and request the fund transfer no later than 30 days post discharge or transfer. This transfer of DAP funds shall apply unless the Department determines that there are extenuating circumstances which justify an exception.

If additional DAP funds other than those provided through the original IDAPP are required to support the individual in the new setting after transfer, the region holding the IDAPP funds for the individual shall provide the additional funding based on approval of a revised IDAPP.

In all cases of an individual residing outside of their original region, DAP funds shall be transferred to the region in which the individual resides within six months of discharge from the hospital.

Individuals who have been adjudicated NGRI and are placed outside of their case management CSB service area or region may have specific conditions associated with their Conditional Release Plan related to, their case management CSB or their area of residence..

Under these conditions, the CSB may choose (or be required) not to reallocate funds and oversight to the new region, in which case the CSB and region of origin shall remain the case management CSB and region of record. The case management CSB is then responsible for all required reporting under the performance contract and conditional release plan.

VI. Reporting (Modify this section and insert applicable details in this section of the reporting operations of the regional program model selected by the RMG.)

A. Performance Contract Requirements:

Participating CSBs and the regional manager shall comply with all of the requirements in Exhibit C of the community services performance contract, including the following reporting requirements.

The regional manager shall submit the quarterly summary of IDAPPs to the Department in a format developed by the Department in consultation with regional managers and Discharge Assistance Program Administrative Manual 27 designated members of VACSB. Quarterly reports will document year-to-date information about ongoing and one-time IDAPPs, including data about each individual receiving DAP services and the amounts of DAP funds approved for each IDAPP (if requested), the total number of IDAPPs that have been implemented, and the total DAP funds obligated for these IDAPPs. The first and third quarter reports are due thirty (30) days following the end of the quarter. The second and fourth quarter reports are due forty-five (45) days after the end of the quarter. It is the participating CSBs’ responsibility to provide the regional manager with accurate information related to actual costs and other revenue to ensure the accuracy of reports.

B. Community Consumer Submission 3 (CCS 3) Reporting:

The case management CSB is responsible for ensuring that the required information about the individual, his/her type of care (Consumer Designation Code for DAP) and the services received are entered in their information system and reported to the Department through the extraction by the CCS 3. CCS 3 submissions must satisfy the requirements in Exhibit I of the performance contract. These requirements apply to all IDAPPs implemented with DAP funds.

CSBs shall assign a 910 Consumer Designation Code only to individuals with ongoing IDAPPs, including ongoing plans that are supported through extended use of onetime funds. Additional information about assigning, initiating, and ending consumer designation codes and about all other aspects of reporting data through the CCS is available in the current Community Consumer Submission 3 Extract Specifications, which is available at http://www.dbhds.virginia.gov/OCC-default.htm.

C. Community Automated Reporting System (CARS) Reporting: The case management CSB responsible for directly providing or purchasing the services in an individual’s IDAPP shall reflect, account for, and report the actual revenues and actual expenses associated with the services in the IDAPP through the mid-year and end of the fiscal year CARS reports. Reports must satisfy the requirements in Exhibit I of the performance contract. These requirements apply to all IDAPPs implemented with DAP funds.

VII. Review and Evaluation

A. Utilization Review: The participating CSBs and state hospital in each region shall develop and implement a utilization review process for all IDAPPs and DAP supported programs. At a minimum, this process (known as “scrubbing”) will include a review of the current IDAPP, services being received or provided, confirmation that the individual’s has applied for and/or is receiving all eligible benefits or entitlements (e.g., Medicaid, insurance, SSI/SSDI, or other sources), amounts of other income received, and confirmation of the residential placement during the quarter.

The RUMCT and/or designated subcommittee shall conduct quarterly utilization reviews of approved IDAPPs to ensure continued appropriateness of services, compliance with Discharge Assistance Program Administrative Manual 28 approved IDAPPs and individual-related events such as re-hospitalizations, incarcerations, or terminations of services. If the region does not have sufficient funds to approve new ongoing DAP requests, the review of existing plans shall occur monthly, or more often if needed.

B. Department Reviews: The Department shall regularly monitor the performance of the regions’ management of the DAP as well as the CSBs’ implementation of IDAPPs. Pursuant to sections 6.f and

1. c in the Community Services Performance Contract, the Department may conduct on-going utilization reviews and analyze information about individuals receiving services, the services they received, and financial information related to the DAP, such as re-hospitalizations, transitions to non-DAP supported services and supports, maximization of other revenue sources, expenditure patterns, use of resources, outcomes, and performance measures to ensure the continued effectiveness and efficiency of the DAP.

The Department shall include the financial and programmatic operations of the DAP as part of its regular CSB Review, which is conducted by multidisciplinary teams including Department fiscal and program staff.

C. Performance Measures: The RUMCT and RMG shall monitor the performance measures established by the Department in the DAP Manual by receiving reports at least quarterly from the regional manager on the DAP’s achievement of the measures. The RMG and participating CSBs shall take actions in a timely manner to address unsatisfactory performance on any measure.

VIII. Term of the MOU

This MOU shall be in effect for one year beginning on July 1, (enter year) and ending on June 30, (enter year). This MOU shall automatically renew for four additional 12-month periods unless terminated in writing as provided below.

IX. Termination of the MOU

Each of the parties is authorized to terminate this MOU if it determines that another party has violated a material term of the MOU. Each of the parties may terminate its obligations under this MOU by giving each of the other parties 60 days written notice. If one or more of the parties gives notice of its desire to terminate the MOU, the parties shall confer to determine whether the DAP may continue in effect without the participation of the terminating party or parties. If the DAP is terminated or the Department reduces state funding for the DAP, participating CSBs shall not be required to continue to provide services that are the subject of this MOU. In the event funding is terminated or reduced, continued access to community services for individuals currently receiving DAP services shall be governed by the existing community services performance contract, CSB policies, and other procedures for the provision of services.

Discharge Assistance Program Administrative Manual 29 X. General Terms and Conditions

A. The parties and the regional manager agree they shall comply in their implementation of the DAP with all applicable provisions of state and federal law and regulations, the provisions and requirements of the DAP Manual, the current community services performance contract, the Discharge Protocols for Community Services Boards and State Hospitals, the current Human Rights and Licensing Regulations, and applicable State Board policies. Applicable provisions of the current community services performance contract include Exhibit C and Appendix E: Regional Program Operating Principles and Appendix F: Regional Program Procedures that are in current Core Services Taxonomy.

If there are any conflicts or inconsistencies between any provisions of this MOU and the current community services performance contract, applicable provisions of the contract shall control. However, this MOU may modify applicable provisions in Appendix F of Core Services Taxonomy to reflect the unique nature of the DAP.

B. Nothing in this MOU shall be construed as authority for any of the parties to make commitments that will bind the other parties beyond the scope of this MOU.

Furthermore, the parties shall not assign, sublet, or subcontract any work related to this MOU or any interest it may have herein without the prior written consent of the other parties.

C. No alteration, amendment, or modification in the provisions of this MOU shall be effective unless put in writing, signed by the parties, and attached hereto.

D. Nothing in this MOU is intended to, nor does it create, any claim or right on behalf of any individual to any services or benefits from any of the parties.

XI. Privacy of Personal and Health Information: For purposes of this section, parties include the regional manager.

A. The parties to this MOU agree to maintain all protected health information (PHI) and personally identifiable information (PII) learned about individuals receiving services confidential and agree to disclose that information only in accordance with applicable state and federal law and regulations, including the regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Virginia Health Records Privacy Act, the Rules and Regulations to Assure the Rights of Individuals Receiving Services from Providers of Mental Health, Developmental, and Substance Abuse Services, and each party’s own privacy policies and practices.

B. Even though each party may not provide services directly to each of the individuals receiving services through DAP and this MOU, the parties may disclose PHI, PII, or other confidential information about individuals to one another under 45 C.F.R. § 164.512(k)(6)(ii) and applicable provisions in the current community services performance contract in order to perform their responsibilities under this MOU, including coordination of the services and functions provided under this MOU and improving the administration and management of the services provided to the individuals receiving Discharge Assistance Program Administrative Manual 30 services hereunder.

C. In carrying out their responsibilities under this MOU, the parties may use and disclose PHI, PII, or other confidential information to one another to perform the functions, activities, or services specified in this MOU on behalf of one another, including utilization review, financial and service management and coordination, collaboration and sharing of information relative to discharge planning and clinical case consultation. In so doing, the parties and the regional manager agree to:

1. not use or further disclose PHI, PII, or other confidential information other than as permitted or required by the terms of this MOU or as required by law;

1. use appropriate safeguards to prevent use or disclosure of PHI, PII, or other confidential information other than as permitted by this MOU;

1. report to the other parties any use or disclosure of PHI, PII, or other confidential information not provided for by this MOU of which they become aware;

1. impose the same requirements and restrictions contained in this MOU on their subcontractors and agents to whom they provide PHI, PII, or other confidential information received from, or created or received by the other parties to perform any services, activities or functions on behalf of the other parties;

1. provide access to PHI, PII, or other confidential information contained in a designated record set to the other parties, in the time and manner designated by the other parties, or, at the request of the other parties, to an individual in order to meet the requirements of 45 CFR 164.524 or applicable provisions in the current community services performance contract;

1. make available PHI, PII, or other confidential information in its records to the other parties for amendment and incorporate any amendments to PHI, PII, or other confidential information in its records at the request of the other parties;

1. document and provide to the other parties information relating to disclosures of PHI, PII, or other confidential information as required for the other parties to respond to a request by an individual for an accounting of disclosures of PHI, PII, or other confidential information in accordance with 45 CFR 164.528;

1. make their internal practices, books, and records relating to use and disclosure of PHI, PII, or other confidential information received from or created or received by the other parties on behalf of the other parties, available to the Secretary of the U.S. Department of Health and Human Services for the purposes of determining compliance with 45 CFR Parts 160 and 164, subparts A and E applicable provisions in the current community services performance;

1. implement administrative, physical, and technical safeguards that reasonably and Discharge Assistance Program Administrative Manual 31 appropriately protect the confidentiality, integrity, and availability of electronic PHI, PII, or other confidential information that they create, receive, maintain, or transmit on behalf of the other parties as required by the HIPAA Security Rule, 45 C.F.R. Parts 160, 162, and 164 applicable provisions in the current community services performance contract;

10. ensure that any agent, including a subcontractor, to whom they provide electronic PHI, PII, or other confidential information agrees to implement reasonable and appropriate safeguards to protect it;

11. report to the other parties any security incident of which they become aware; and

12. at termination of this MOU, if feasible, return or destroy all PHI, PII, or other confidential information received from or created or received by the parties on behalf of the other parties that the parties still maintain in any form and retain no copies of such information or, if such return or destruction is not feasible, extend the protections of this MOU to the information and limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible.

D. Each of the parties may use and disclose PHI, PII, or other confidential information received from the other parties, if necessary, to carry out its legal responsibilities and for the proper management and administration of its business. Each of the parties may disclose PHI, PII, or other confidential information for such purposes if the disclosure is required by law, or if the party obtains reasonable assurances from the person to whom the PHI, PII, or other confidential information is disclosed that it will be held confidentially, that it will be used or further disclosed only as required by law or for the purpose for which it was disclosed to the person, and that the person will notify the party of any instances of which it is aware in which the confidentiality of the information has been breached

E. All parties shall encrypt transmissions of DAP-related information and data about individuals receiving DAP services, including all forms and reports containing PHI PII, or other confidential information, in a manner specified in the community services performance contract and pursuant to the applicable provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) and subsequent implementing regulations.

Discharge Assistance Program Administrative Manual 32

IN WITNESS WHEREOF, the parties have caused this agreement to be duly executed, intending to be bound thereby.

________________________________________________ __________________ (type name of executive director under signature line)

Date Executive Director, (insert name of CSB)

________________________________________________ _________________ (type name of executive director under signature line)

Date Executive Director, (insert name of CSB)

________________________________________________ _________________ (type name of executive director under signature line)

Date Executive Director, (insert name of CSB)

________________________________________________ _________________ (type name of executive director under signature line)

Date Executive Director, (insert name of CSB)

________________________________________________ __________________ (type name of executive director under signature line)

Date Executive Director, (insert name of CSB)

________________________________________________ __________________ (type name of executive director under signature line)

Date Executive Director, (insert name of CSB)

________________________________________________ __________________ (type name of executive director under signature line)

Date Executive Director, (insert name of CSB)

________________________________________________ ________________ (type name of state hospital director under signature line)

Date Director, (insert name of state hospital)

33 Appendix C: Clinical Readiness for Discharge Rating Scale

Treatment teams shall rate the clinical readiness for discharge of all individuals receiving services in state hospitals at least monthly using the following scale.

1. Clinically Ready for Discharge: The individual meets any of the following criteria. a. has met treatment goals and does not need inpatient psychiatric treatment b. NGRI with up to 48 hour privilege level c. NGRI under a temporary custody order and at least one forensic evaluator has recommended conditional or unconditional release and there is a pending court date d. NGRI on revocation status and the treatment team and CSB recommend conditional or unconditional release and there is a pending court hearing

1. Almost Clinically Ready for Discharge: The individual meets any of the following criteria. a. needs additional inpatient care to fully address clinical issues and/or there is concern about adjustment difficulties b. can take community trial visits to assess readiness for discharge; may have the civil privilege level to go on overnight temporary visits c. resistant to discharge and refuses to engage in discharge process d. NGRI with unescorted community visits privilege

1. Not Clinically Ready for Discharge: The individual meets any of the following criteria. a. participates in treatment (engaged, adherent with medications, groups. etc.) but unable to function independent of 24 hour supervision in an inpatient psychiatric setting b. not yet able to take independent passes or take trial passes to a supervised placement but may have unescorted grounds privileges if available at the hospital c. NGRI and does not have unescorted community visits privilege

1. Significant Clinical Instability Limiting Privileges and Engagement in Treatment: The individual meets any of the following criteria. a. not psychiatrically stable b. requires constant 24 hour supervision in an inpatient psychiatric setting c. presents significant risk and/or behavioral management issues d. acutely psychotic

Notes: Discharge planning begins on admission and should be active throughout the individual’s hospitalization independent of his or her clinical readiness for discharge rating. An individual may be clinically ready for discharge before the rating is formally completed.

34 Appendix D: Community Services Performance Contract Exhibit C: Discharge Assistance Program Requirements

The Department and the CSB agree to implement the following requirements for management and utilization of all current regional state DAP funds to enhance monitoring of and financial accountability for DAP funding, decrease the number of individuals on state hospital extraordinary barriers to discharge lists (EBLs), and return the greatest number of individuals from state hospitals to their communities.

1. The Department shall work with the VACSB, representative CSBs, and regional managers to develop clear and consistent criteria for identification of individuals who would benefit from use of DAP to support their discharge and acceptable uses of regional state DAP funds and standard terminology that all CSBs and regions shall use for collecting and reporting data about individuals, services, revenues, expenditures, and costs.

1. The CSB shall comply with the current Discharge Assistance Program Manual issued by the Department, which by agreement of the parties is hereby incorporated into and made a part of this contract by reference. If there are conflicts or inconsistencies between the Manual and this contract, applicable provisions of the contract shall control.

1. All regional state DAP funds allocated within the region shall be managed by the regional management group (RMG) and the regional utilization management and consultation team (RUMCT) on which the CSB participates in accordance with Appendices E and F of the current Core Services Taxonomy.

1. The CSB, through the RMG and RUMCT on which it participates, shall ensure that other funds such as Medicaid payments are used to offset the costs of approved IDAPPs to the greatest extent possible so that regional state DAP funds can be used to implement additional DAP services and supports to reduce EBLs.

1. On behalf of the CSBs in the region, the regional manager funded by the Department and employed by a participating CSB shall submit mid-year and end of the fiscal year reports to the Department in a format developed by the Department in consultation with regional managers that separately displays the total actual year-to-date expenditures of regional state DAP funds for ongoing IDAPPs and for one-time IDAPPs and the amounts of obligated but unspent regional state DAP funds.

1. If CSBs in the region cannot expend at least 90 percent and obligate at least 95 percent of the total annual regional state DAP fund allocations on a regional basis by the end of the fiscal year, the Department may work with the RMG and participating CSBs to transfer regional state DAP funds to other regions to reduce EBLs to the greatest extent possible, unless the Department determines that there are extenuating circumstances which justify an exception.

1. On behalf of the CSBs in a region, the regional manager shall continue submitting the quarterly summary of IDAPPs to the Department in a format developed by the Department in consultation with regional managers that displays year-to-date information about ongoing

35 and one-time IDAPPs, including data about each individual receiving DAP services, the amounts of regional state DAP funds approved for each IDAPP, the total number of IDAPPs that have been implemented, and the projected total net regional state DAP funds obligated for these IDAPPs.

1. The Department, pursuant to sections 6.f and 7.g of this contract, may conduct utilization reviews of the CSB or region at any time to confirm the effective utilization of regional state DAP funds and the implementation of all approved ongoing and one-time IDAPPs.

36 Appendix E: DAP Performance Measures

Data Performance Measures Data Sources for Measures

Utilization of State Hospital Bed Days by Individuals Before and After Enrollment in DAP State Hospital Bed Days Used by DAP-Enrolled Individuals Over Equal Time Periods Pre- and Post-DAP Enrollment

CCS 3 Type of Care and Service Records

AVATAR

Readmission to a State Hospital within 30 and 180 Days After Enrollment in DAP Percent of 30 and 180 Day State Hospital Readmissions by Individuals Enrolled in DAP ÷ Percent of 30 and 180 Day State Hospital Readmissions by All Adults During the Reporting Period CCS 3 Type of Care and Service Records

AVATAR

Admission to a State Hospital After Release From a DAP Episode of Care Individuals Admitted to a State Hospital Within 60 Days of Release From a DAP Episode of Care ÷ Total Number of Individuals Released From DAP During the Reporting Period CCS 3 Type of Care and Service Records

AVATAR

Individuals Discharged to DAP From a State Hospital Extraordinary Barrier List (EBL) State Hospital EBL Individuals Discharged to DAP ÷ All Individuals Newly Enrolled in DAP During the Reporting Period CCS 3 Type of Care and Service Records

AVATAR

Utilization of State DAP Funds Total State DAP Funds Expended ÷ Total State DAP Funds Allocated During the Reporting Period for Each Region Quarterly DAP Reports

CARS

Housing Stability (deferred) Number of Individuals in DAP with No More Than One Housing Move ÷ Total Number of Individuals in DAP During an Annual Reporting Period CCS Consumer Record and Type of Care Record

37 Appendix F: Notes and Sources for DAP Performance Measures

1. Data for all measures can be displayed statewide, by region, and by individual CSB.
2. Number of individuals receiving DAP services is derived from the CCS 3 Type of Care (910 Code) and Service (receipt of valid mental health services) Records.
3. Number of individuals completing a DAP episode of care (released from the DAP) is derived from the CCS 3 Type of Care (910 Code and type of care through date).
4. Number of individuals admitted to a state hospital is derived from AVATAR.
5. Number of state hospital beds is derived from AVATAR.
6. Number of individuals enrolled in Medicaid: CCS 3 Consumer Record (insurance type and Medicaid number) and quarterly DAP reports.
7. Number of individuals for whom Medicaid payments have been received is derived from quarterly DAP reports.
8. Amount of state DAP funds allocated is derived from CARS reports.
9. Amount of state DAP funds expended is derived from Quarterly DAP Reports. 10. Changes in residence are derived from the CCS 3 Consumer Record (Data Element 88).

Discharge Assistance Program Administrative Manual

Virginia Department of Behavioral Health and Developmental Services

Effective April 1, 2018 Discharge Assistance Program Manual 1 Table of Contents Page

1. Background of the DAP
2. Purpose of the DAP 2
3. General Requirements 3
4. DAP Management Structure 3

a. Regional Program Model 3

b. Regional Management Group (RMG) 3

c. Regional Utilization Management and Consultation Team (RUMCT) 4

d. RUMCT Responsibilities 4

e. Department Staff Participation 5

1. DAP Financial Management 5

a. Allocation and Re-allocation of State DAP Funds 5

b. Disbursement of State DAP Funds 6

c. Allowable Uses of State DAP Funds 6

d. Maximizing Other Funding and Revenue Sources 7

e. Unexpended State DAP Funds 7

1. DAP Service Management 8

a. Discharge Readiness 8

b. Extraordinary Barriers to Discharge List Monitoring and Reporting 8

c. Development of Individualized Discharge Assistance Program Plans 8

d. Monitoring of Individualized Discharge Assistance Program Plans 8

e. Rehospitalization 9

1. Transfers of Individuals Among CSBs and Regions 10
2. Reporting 11

a. Performance Contract Reporting Requirements 11

b. Community Consumer Submission 3 (CCS 3) Reporting 11

c. Community Automated Reporting System (CARS) Reporting 12

1. Review and Evaluation 12

a. Regional Utilization Reviews 12

b. Department Reviews 12

c. Performance Measures 12 Appendices A. Definitions 13 B. Model Memorandum of Understanding 15 C. Clinical Readiness for Discharge Rating Scale 30 D. Community Services Performance Contract Exhibit C 31 E. DAP Performance Measures 33 F. Notes and Sources for Performance measures 34 Discharge Assistance Program Administrative Manual 2

1. Background of the DAP

The Department of Behavioral Health and Developmental Services (Department) initiated the Discharge Assistance Program (DAP) in 1998. The DAP supports the Department’s commitment to person-centered and recovery based care and its vision of a system of services and supports driven by individuals receiving services that promotes self-determination, empowerment, recovery, resilience, health, and the highest level of participation by individuals receiving services in all aspects of community life, including work, school, family, and other meaningful relationships. The DAP is supported with a pool of state mental health funds allocated to each DBHDS region (Region) to implement community capacity and/or individualized services and supports that enable adults receiving services in state hospitals to live in the community. The DAP offers a flexible approach for responding to barriers to discharge from state hospitals once an individual has been determined to be clinically ready for discharge.

CSBs, via Regions, use DAP to support services enabling individuals to transition from state hospitals to least restrictive, most integrated community settings.

Regional DAP funds are used for hospital individuals whose needs exceed typical CSB services or lack funding to access them.

Usually these individuals have had long lengths of stay in the hospital and have complex conditions or specialized needs that create barriers to discharge. These barriers often include one or more of the following: ● a forensic legal status; ● absence of guardians or authorized representatives; ● lack of affordable housing with sufficient and reliable services and supports that are necessary to enable independent living; ● challenging behaviors or conditions, including complex psychiatric symptoms or significant behaviors, that are difficult to manage and make it difficult to identify willing providers; or ● complex medical and/or chronic health conditions;

1. Purpose of the DAP

This manual provides CSBs and Regions with DAP guidelines.

The DAP's purposes include serving discharged individuals and transitioning them to non-DAP services when possible.

B. to serve adults in state hospitals clinically ready for discharge requiring additional funding for community placement through development, funding, implementation, and review of discharge assistance funds.

Discharge Assistance Program Administrative Manual 3 C. to fund start-up and ongoing costs for community services enabling hospital discharges.

This manual outlines a uniform mechanism for CSBs and Regions to manage, coordinate, monitor DAP-funded IDAPP services and resource utilization.

1. General Requirements

A. The CSBs and state hospital in each region shall develop a memorandum of understanding (MOU) that outlines the region’s practices, processes, and timelines for ensuring compliance with the requirements in this manual. The MOU shall be consistent with the applicable regional provisions and procedures of the current Core Services Taxonomy. The fiscal agent CSB shall ensure the MOU is available for the Department’s review. A model MOU is contained in Appendix B of this manual.

B. CSBs, regional managers, and the Department shall implement DAP in compliance with all applicable laws, regulations, this manual, the community services contract, discharge protocols, Human Rights and Licensing Regulations, and State Board policies.

Applicable provisions of the current Community Services Performance Contract (CSPC) include Exhibit C, attached to this manual as Appendix D, Appendix E: Regional Program Operating Principles and Appendix F: Regional Program Procedures that are in the most recent Core Services Taxonomy, available at http://www.dbhds.virginia.gov. If there are any conflicts or inconsistencies between the current CSPC and this manual, the applicable provisions of the CSPC shall control. However, this manual modifies applicable provisions in Appendix F of the current version of the Core Services Taxonomy to reflect the unique nature of the DAP.

C. All participating CSBs, regional managers, state hospitals, and the Department shall encrypt DAP-related data, including PHI and PII, as specified in the community services contract and HIPAA regulations.

D. No exceptions or amendments are effective without Department review, approval, dating, and inclusion in this manual.

1. DAP Management Structure A. Regional Program Model: Participating CSBs shall select a regional program model from Appendix E of the current Core Services Taxonomy for the operation of the regional DAP and reflect this model in the MOU developed pursuant to section 3.a of this manual.

Discharge Assistance Program Administrative Manual 4

B. Regional Management Group (RMG): The participating CSBs and the state hospital serving the region shall establish a RMG. The executive director of each participating CSB and the director of the state hospital shall serve on or appoint one member to the RMG. The RMG shall establish and monitor the operation of a Regional Utilization Management and Consultation Team (RUMCT). The RMG shall:

1. Manage the DAP and coordinate funding use, including reallocating state DAP funds among CSBs and regions as needed;
2. Ensure effective use of DAP services and resources; and
3. assure that the guidelines outlined in the manual are consistently applied in the administration of DAP.

The RMG may authorize the employment of a regional manager and the necessary staff to administer the DAP with funds drawn from existing regional resources. The RMG shall identify the job description of all staff and identify which CSB will provide supervision of the regional manager and staff. The establishment and operation of the RMG shall be described in the MOU implemented by the participating CSBs and state hospital. The RMG shall comply with the applicable provisions the Regional Program Operating Principles and the Regional Program Procedures that are in the current Core Services Taxonomy. In many instances, the responsibilities will be carried out by participating CSBs, the participating state hospital, or the regional manager.

C. Regional Utilization Management and Consultation Team (RUMCT): The RUMCT shall consist of representatives from participating CSBs in the region, participating state hospitals, and others as may be appointed by the RMG, such as the regional manager. The positions of the representatives who serve on this team shall be identified in the MOU. Since DAP is only one component of the utilization management functions of the RUMCT, a subcommittee designated by the RUMCT may be given authority to perform the functions described in this section. The RUMCT, through the regional manager and participating CSBs, shall ensure compliance with the documentation required for IDAPP submission and review. The establishment and operation of the RUMCT shall be described in the MOU implemented by the participating CSBs and state hospital. The RUMCT shall comply with the applicable provisions of the Regional Program Operating Principles and the Regional Program Procedures that are in the current Core Services Taxonomy D. RUMCT Responsibilities: The responsibilities of the RUMCT will be carried out by designated representatives of the CSBs and the state hospital serving the region, designated subcommittees, and/or the regional manager. The RUMCT shall:

1. Review proposed IDAPPs to ensure services meet individuals’ needs and promote stability in the community.

Discharge Assistance Program Administrative Manual 5

1. Jointly review all IDAPPs quarterly; plans are reviewed monthly or as needed to assess funding for DAP approval requests with insufficient funds.
2. the utilization review by the RUMCT will ensure the: a. continued appropriateness of services, b. implementation of approved IDAPPS, including the review of events related to the individual such as re-hospitalization, incarceration relocation, etc. c. ensure accurate financial information is provided by their CSB to the regional managers for quarterly reports d. address reductions in service levels and/or discontinuation of DAP services resulting in available funds. e. This review process may revise IDAPPS, adjust, or redistribute DAP funds.
3. Review clinically ready individuals, especially on the EBL, to identify or recommend community services and funding; RUMCT will inform RMG of results and actions.
4. Facilitate, upon CSB request, resolution of issues delaying discharge or affecting community tenure.
5. Identify opportunities for CSBs to collaborate on programs or placements for faster discharge from state hospitals.
6. Review and endorse all new IDAPPs (ongoing or one-time) via in person, email, or other technology.
7. Review DAP proposals to increase community capacity before submitting for Department approval.

As a member of the RUMCT, the regional manager, in collaboration with the participating CSBs, shall maintain a current database on all individuals receiving DAP-funded services.

This database shall include electronic copies of all on-going or one-time IDAPPs. All IDAPPs shall be submitted using the Department approved form. The regional manager shall maintain automated back-up data transferable by encryption on all regional DAP activities.

E. Department Staff Participation: Although not members of RMG or RUMCT, designated Department staff shall have access to all meetings and documents maintained or used by these bodies, as described in the current Community Service Performance Contract. DBHDS staff may attend and participate in all meetings or other related activities of the region.

Discharge Assistance Program Administrative Manual 6

1. DAP Financial Management

A. Allocation and Re-allocation of State DAP Funds: Effective in FY 2015, all mental health DAP funds were designated and distributed as regional funds.

All DAP funds are restricted; CSBs must track, account, and report expenditures separately in CARS and DAP reports.

Restricted funds, including unspent prior year balances, cannot be used for purposes other than DAP.

B. Disbursement of State DAP Funds: The Department disburses regional DAP funds directly to the CSB acting as the DAP fiscal agent for the region, as part of the regular semi-monthly CSB payments. The fiscal agent CSB administers these funds and distributes the funds for payment of delivered services and/or as determined by the RMG and as described in the regional MOU.

The fiscal CSB receives DAP funds from the Department via its community services contract. The fiscal agent CSB for the region must ensure that previously approved IDAPPs continue to be funded first.

Regions should over-allocate and adjust plans to maximize fund use. If insufficient funds exist for approved plans exceeding the allocation, DBHDS will ensure coverage.

C. Allowable Uses of State DAP Funds:

1. DAP funds allocated to regions and disbursed to participating CSBs shall be used for the discharge and community support of individuals for whom IDAPPs have been approved by the RUMCT or for DBHDS approved community infrastructure development or service expansion that directly and measurably facilitates state hospital discharges.
2. DAP funding may be used for any approved combination of services that meet individuals' needs with IDAPPs in the most integrated, least restrictive community settings.
3. Regions must use DAP funds only to support the costs of approved ongoing or one-time IDAPPs or DBHDS approved community infrastructure development or service expansion that directly and measurably facilitates state hospital discharges. Any other use of DAP funds is not allowed and funds used for other purposes are subject to recovery by the Department.
4. Regions shall prioritize DAP funds for individuals with the greatest tenure on the EBL, subject to fund availability and discharge facilitation capacity.

Discharge Assistance Program Administrative Manual 7

1. Regions may use DAP funds to pay for medications as part of an approved IDAPP only after other sources of support for medications have been exhausted. These sources include state MH Pharmacy-Medication Support funds that are allocated to CSBs, indigent care programs offered by most pharmaceutical manufactures, and Medicaid.

Medicare Part D, the prescription drug benefit, requires true out of pocket costs. DAP funds may not be used on behalf of a Part D beneficiary, (e.g., assistance with copayments). DAP funds do not meet federal out-of-pocket cost requirements of Part D.

1. Regions cannot use DAP funds for individuals in state-funded PACT, except for direct residential costs like rent, housing subsidies, or non-PACT services.
2. Regions cannot use DAP funds for individuals already in the community who were previously discharged or received DAP services but no longer have an authorized IDAPP by RUMCT.
3. Regions cannot use DAP funds for CSB staff positions or programs unrelated to specific individual needs in ongoing IDAPPs.

This includes CSB hospital liaison positions.

1. Regions cannot approve the use of DAP funds as direct income to any individual receiving DAP services. DAP funds are not individual entitlements and cannot be used to provide personal income to individuals receiving DAP services. 10. For non-Medicaid individuals receiving State Plan or Clinic services, costs must not exceed the usual cost or frequency.

D. Maximizing Other Funding and Revenue Sources: The region must use DAP funds as the funding source of last resort for all IDAPPs. The RMG, RUMCT and the participating CSBs shall ensure that other funds such as Medicaid payments, other appropriate state general funds, fees paid by individuals receiving services, and other third-party funding sources are used to offset the costs of approved IDAPPs to the greatest extent possible so that state DAP funds can be used to discharge the greatest number of individuals from state hospitals. The costs of an IDAPP must be adjusted to reflect other sources of funding or revenues that are identified and obtained. In cases where application was made for benefits to be started/reinstated upon discharge from the hospitals, CSBs will monitor the status of the application monthly. CSBs will inform providers of expectations to back bill Medicaid whenever possible and return any DAP paybacks to the Region and will monitor compliance. This shall be documented in records maintained by the CSB and the regional manager and in reports submitted to the Department.

E. Unexpended State DAP Funds: Generally, the use of unspent DAP funds is governed by Appendix C of the CSB Administrative Requirements, incorporated by reference and agreement of the parties into the current community service performance contract and available on the Office of Support Services page of the Department’s web site at http://www.dbhds.virginia.gov. All DAP funds are restricted. Any DAP funds that remain unspent at the end of the fiscal year in which they were disbursed by the Department shall remain restricted funds. Consequently, those unspent Discharge Assistance Program Administrative Manual 8 DAP funds cannot be used for other purposes and shall be used by regions and participating CSBs to defray the costs of current IDAPPs before current fiscal year state DAP funds are used. Balances of unspent state DAP funds that are not used within the fiscal year in which they were allocated are subject to recovery by the Department through future payments to regional fiscal agent CSB.

During the fiscal year, unexpended DAP funds may accrue as a result of delays in discharges, re-hospitalization or incarceration of an individual receiving DAP services, reductions in services in approved IDAPPs, termination of an IDAPP, and/or changes in allocations among CSBs. The RUMCT, with authorization from the RMG, may approve the use of any of its unexpended DAP funds only for the following priorities:

1. for one-time IDAPPs to support the discharge of individuals in the state hospital;
2. for addressing the one-time needs of individuals with existing IDAPPs;
3. for transitional costs of individuals determined to be NGRI as part of the privileging process or for other individuals in state hospitals with documented clinical needs for transitional services and supports in order to be discharged. This may at times be an exception to the requirement that the individual be ‘ready for discharge’ as advancement through the NGRI privileging process requires trial passes;
4. for temporary funding to supplement an IDAPP while the CSB obtains benefits for an individual;
5. when needed, to cover the cost of obtaining a guardian for an individual in a state hospital. This process may begin prior to the individual becoming clinically ready for discharge in order to prevent the guardianship process from delaying discharge when the individual is clinically ready.
6. in specific cases and with the approval of the RUMCT, large one-time fund IDAPPS may be granted to individuals requiring on-going supports when on-going DAP dollars are not available at the time of discharge. In those cases, there is no time limitation on the one-time support. However, these individuals must be reported in CCS3 and be given a 910 Code designation.
7. for developing and/or expanding regional infrastructure to enable the discharge of individuals in state hospitals, such as residential resources or other community placements. When DAP funds are used to create community capacity, the specific use of the funds, the individuals discharged and services provided as a result of the infrastructure will be reported annually along with the year-end IDAPP report to

DBHDS.

If a region expends less than 90% of its DAP allocation for active plans and obligates less than 95% of its funds by year's end, the Department will transfer unspent funds to other regions unless extenuating circumstances exist.

Discharge Assistance Program Administrative Manual 9

1. Census Management A. Discharge Readiness: Participating CSBs shall develop the discharge plan in consultation with the individual, guardian or authorized representative, and the state hospital treatment team. This plan describes the specific community mental health, developmental, substance abuse, employment, health, educational, housing, recreation, transportation, legal, and advocacy services and supports needed by the individual following an episode of hospitalization and identifies the providers that have agreed to provide these services to the individual.

B. Clinically Ready for Discharge Monitoring: The participating CSBs through the RUMCT and regional manager shall monitor individuals who are clinically ready for discharge at the state hospital serving the region monthly to track individuals for whom they are the case management CSB and ensure the individuals are discharged as soon as possible.

C. Development of Individualized Discharge Assistance Program Plans:

1. The case management CSB, the individual being discharged, his/her guardian or authorized representative, and the state hospital treatment team shall determine the most appropriate services and placement in the community for the individual that are consistent with his or her choices to the greatest extent possible.
2. DAP services and supports must be documented on the IDAPP, and the IDAPP must be consistent with the individual’s preferences and choices to the greatest extent possible.
3. All individuals with on-going IDAPPs must receive case management services or documented CSB monitoring. This shall be documented monthly in progress notes by the case management CSB and used to provide updates during regional DAP scrubbings.
4. The IDAPP shall be completed and endorsed by all relevant parties. The case management CSB must submit a brief narrative describing the individual needs and proposed plan, identified placement, projected discharge date, and an explanation of all revenues and costs with all new or renewing IDAPPs. The explanation of costs shall include a justification/explanation as to why DAP is a last-resort funding source, particularly for individuals who have Medicaid/Medicare, or will become eligible for these benefits upon discharge. New IDAPPs must identify all the services the individual needs to successfully transition to the community, the providers who have agreed to provide the services, and a projected discharge date. IDAPP must show all revenues by source and projected expenses.

D. Monitoring of IDAPPs: The RUMCT or its designee shall review at least quarterly the implementation of all IDAPPs to ensure the effective and efficient utilization of the DAP funds. If the region does not have sufficient funds to approve new ongoing DAP requests, the review of existing plans shall occur monthly, or more often if needed. The RUMCT shall develop a process of communication to ensure that the RMG is informed of the utilization review activities.

If the CSB cannot implement an approved IDAPP within 30 days of discharge, actions must be taken within 30 days after the projected discharge date. Discharge Assistance Program Administrative Manual 10

1. The region shall identify and discharge another individual who is on the EBL or who has been determined to be clinically ready for discharge and for whom DAP funding is appropriate for addressing the barriers to that individual’s discharge;

If not done within 30 days, IDAPP funds revert to RUMCT for discharge from another region on the EBL, per C.4., for individuals needing DAP support.

1. Should an individual who has been adjudicated Not Guilty by Reason of Insanity (NGRI) not be discharged within 30 days of the projected discharge date due to circumstances beyond the control of the individual, CSB and/or state hospital; the CSB shall send a memo to the RUMCT with an explanation of said circumstance.

Examples of these circumstance could include, but not limited to: IFPC and/or FRP revision requests, residential provider withdrawing acceptance for reasons not related to the individual’s behavior, the NGRI court’s delay in scheduling a conditional release hearing date, etc. The RUMCT shall make a decision to continue funding IDAPP based on the facts presented.

E. Rehospitalization: Upon occasion it may be necessary for DAP enrollees to receive in-patient psychiatric services or be incarcerated. Should this occur, the case management CSB will notify the RUMCT. The RUMCT then may select from the following options:

1. If the RUMCT approves a written request from the CSB, it will stop current payments and resume payments upon the individual’s discharge, if that date is within an agreed upon number of days not to exceed 90 days from the date of re-hospitalization in a state hospital;
2. If the CSB submits a request to the RUMCT that states re-hospitalization will exceed 30 days and on-going funds will be needed to maintain the individual’s residence for an agreed upon period not to exceed 90 days, the RUMCT may approve the provision of the necessary funds during that period only in the amount required to maintain the individual’s place of residence. The RMG shall redistribute any resulting unspent funds in accordance with the provisions in this manual; or
3. The CSB returns the state DAP funds, less year-to-date expenditures, for the unimplemented IDAPP to the RUMCT for redistribution.

Note: The cost of supporting a substitute individual shall not exceed the amount requested in the originally approved IDAPP unless funding is available and approved by the RUMCT.

If service costs are less than requested, unspent funds will be available for redistribution by RUMCT.

For all IDAPPs where the service provider is not the CSB, the CSB shall develop a purchase of service agreement, memorandum of agreement, or other instrument consistent with the CSBs’ purchasing policies and procedures. All such instruments shall be maintained by the affected CSBs and available to the Department upon request.

Discharge Assistance Program Administrative Manual 11

1. Transfers of Individuals Between CSBs or Regions (These instructions apply unless the Department determines that there are extenuating circumstances which justify an exception) A. In the case of individuals transferring between CSBs, the CSB in the chosen locality becomes the receiving case management CSB and works with the original case management CSB, the individual, and the state hospital to effect a smooth discharge and transition to the community. The case management CSB of origin is responsible for the completion of the discharge plan, and shall collaborate with the receiving CSB. Effective July 1, 2018 DAP funds will be transferred from the originating/home CSB to the receiving CSB within 6 months of the individual’s transition.

B. The receiving region accepts IDAPP funds transfer, assumes reporting duties, and must notify regional managers and the Department of changes or requests within 30 days post-discharge or transfer.

C. If extra DAP funds are needed after transfer, the region with the original IDAPP shall provide additional funding upon IDAPP revision approval.

D. If a DAP individual moves within the region, the new CSB assumes case management and reporting responsibilities.

E. If a DAP individual resides outside their DBHDS region, regions and CSBs shall collaborate to address needs and preferences.

F. NGRI individuals placed outside their CSB region may have Conditional Release Plan conditions related to their CSB or residence.

Under these conditions, the CSB may choose (or be required) not to reallocate funds and oversight to the new region, in which case the CSB and region of origin shall remain the case management CSB and region of record. The case management CSB is then responsible for all required reporting under the performance contract and conditional release plan.

Resolution process:

A. When transfer disagreements occur, regional utilization teams shall attempt resolution; if unresolved, managers notify their CSB Regional Chair.

B. Regional chairs shall attempt to resolve transfer disagreements.

C. If unresolved, managers shall within two weeks of the chairs’ meeting request dispute resolution from the Director of Acute Care (or designee).

D. The Director of Acute Care (or designee) will review information, consult parties, and decide on DAP transfer.

E. During the process outlined above, the individual’s placement and services shall not be delayed. The resolution process will simply address regional “ownership” of the DAP funds and case management CSB designation.

1. Reporting A. Performance Contract Reporting Requirements: Participating CSBs and regional managers shall comply with all of the requirements in Exhibit C of the community services performance contract, contained in this manual as Appendix D, including the following reporting requirements.

The regional manager shall submit the quarterly summary of IDAPPs to the Department in a format reviewed by the Department in consultation with regional managers and designated members of VACSB. Quarterly reports will document year-to-date information about ongoing and one-time IDAPPs, including data about each individual receiving DAP services, the amounts of DAP funds approved for each IDAPP, the total number of IDAPPs that have been implemented, and the total DAP funds obligated for these IDAPPs. The first and third quarter reports are due thirty (30) days following the end of the quarter. The second and fourth quarter reports are due forty-five (45) days after the end of the quarter. It is the participating CSB’s responsibility to provide the regional manager with accurate information related to actual costs and other data to ensure the accuracy of reports. Reports on DAP funding that is used to increase community capacity will be due at the end of each fiscal year, or as otherwise required by DBHDS.

B. Community Consumer Submission 3 (CCS 3) Reporting:

The case management CSB is responsible for ensuring that the required information about the individual, his/her type of care (Consumer Designation Code for DAP) and the services received are entered in their information system and reported to the Department through the extraction by the CCS 3. CCS 3 submissions must satisfy the requirements in Exhibit I of the performance contract. These requirements apply to all IDAPPs implemented with DAP funds.

CSBs shall assign a 910 Consumer Designation Code only to individuals with ongoing IDAPPs, including those funded through extended use of onetime funds. Additional information about assigning, initiating, and ending consumer designation codes and about all other aspects of reporting data through the CCS is available in the current Community Discharge Assistance Program Administrative Manual 13 Consumer Submission 3 Extract Specifications, which is available at http://www.dbhds.virginia.gov/professionals-and-service-providers/office-of-support-services C. Community Automated Reporting System (CARS) Reporting: The case management CSB responsible for directly providing or purchasing the services in an individual’s IDAPP shall reflect, account for, and report the actual revenues and actual expenses associated with the services in the IDAPP through the mid-year and end of the fiscal year CARS reports. Reports must satisfy the requirements in Exhibit I of the performance contract. These requirements apply to all IDAPPs implemented with DAP funds.

1. Reviews and Evaluation A. Utilization Review: The participating CSBs and state hospital in each region shall develop and implement a utilization review process for all IDAPPs. At a minimum, this process (known as “scrubbing”) will include a review of the current IDAPPs, services being received, confirmation that the individual has applied for and/or is receiving all eligible benefits or entitlements (e.g., Medicaid, insurance, SSI/SSDI, or other sources), amounts of other income received, and confirmation of the residential placement during the quarter.

RUMCT or subcommittee shall quarterly review IDAPPs for service appropriateness, compliance, and events like re-hospitalizations, incarcerations, or terminations.

If unallocated DAP funds are insufficient for new plans, RUMCT will review existing plans monthly or more to identify unused funds.

B. Department Review: The Department shall regularly monitor the performance of the regions’ management of the DAP as well as the CSBs’ implementation of IDDAPs. Pursuant to sections 6.f and 7.c in the CSPC, the Department may conduct on-going utilization reviews and analyze information about individuals receiving services, the services they received, and financial information related to the DAP, such as re-hospitalizations, transitions to non-DAP supported services and supports, maximization of other revenue sources, expenditure patterns, use of resources, outcomes, and performance measures to ensure the continued effectiveness and efficiency of the DAP.

The Department shall include DAP financial and program operations in its regular CSB Review conducted by multidisciplinary teams including fiscal and program staff. CSBs are identified for review through standard risk management criteria.

Discharge Assistance Program Administrative Manual 14 C. Performance Measures: The Department has developed performance measures for the DAP to assess the effectiveness of the DAP. These measures use existing data sources to avoid imposing additional workload burdens on CSBs, state facilities, and regional managers. The current set of measures is contained in Appendix E of this manual. The RUMCT and RMG shall monitor the performance measures established by the Department through reports provided by the Department. The RMG and participating CSBs shall take action in a timely manner to address unsatisfactory performance on any measure.

Discharge Assistance Program Administrative Manual 15 Appendix A: Definitions

Case Management Community Services Board (CSB) means the CSB that serves the area in which an adult resides. The case management CSB is responsible for case management, liaison with the state hospital when an individual is admitted, and discharge planning. Reference in this manual to CSB means case management CSB, unless the context clearly indicates otherwise, and CSB includes the behavioral health authority established pursuant to § 37.2-601of the Code of Virginia. CSB and BHA are defined in § 37.2-100 of the Code of Virginia.

CARS is the Department software used by CSBs to report service types, capacities, costs, revenues, and expenses by program area and for emergency and ancillary services. CSBs submit mid-year and year-end reports.

CCS 3 is the Department software used by CSBs to report data on individuals receiving mental health, developmental, substance abuse, emergency, and ancillary services, including service types and amounts.

CSBs submit CCS 3 extracts monthly.

Clinical Readiness for Discharge means the determination that an individual is clinically ready for discharge from a state hospital. All state hospitals and CSBs make this determination consistently using the standard clinical readiness for discharge rating scale established by the Department. The rating scale is contained in Appendix C.

Discharge plan means an individualized plan for post-hospital services that is developed by the CSB in consultation with the individual, guardian or authorized representative if one has been appointed or designated or if one is needed, and the state hospital treatment team. This plan is required by § 37.2-505 or § 37.2-608 of the Code of Virginia, and it describes the specific community mental health, developmental, substance abuse, employment, health, educational, housing, recreation, transportation, legal, and advocacy services and supports needed by the individual following an episode of hospitalization and identifies the providers that have agreed to provide these services and supports.

EBL is the list of adults clinically ready for discharge (Level 1) but remaining in hospital over 14 days after determination, generated by the Department and hospitals.

IDAPP is the plan developed by the case management CSB, approved by RUMCT, detailing services, supports, types, amounts, revenues, and costs for discharge.

Ongoing DAP Request is an IDAPP for continuous services/supports to the individual.

Discharge Assistance Program Administrative Manual 16 One-time DAP Request means an IDAPP for services and/or supports to be provided to an individual on a time-limited basis. One time DAP requests are not renewable.

Performance Contract means the contract between the Department and a CSB that defines the responsibilities of and requirements on each party for delivery of services, reporting data about individuals receiving services and the services they receive, service quality, performance and outcome measures, and programmatic and fiscal accountability. The contract is the primary accountability mechanism between the Department and CSBs.

DBHDS Region is a designated group of CSBs and a state hospital addressing regional challenges, needs, planning, and initiatives within a defined area.

Regional participants include CSB, hospital, private providers, individuals, families, advocates, and stakeholders within the region.

Regional Management Group (RMG) means the group established in a DBHDS region by the participating CSBs and state hospital that oversees the management of regional programs and the use of regional resources, including state funds. The RMG consists of the executive director of each CSB and the region’s state hospital director.

Regional Utilization Management and Consultation Team (RUMCT), also referred to as Regional Utilization Management (RUM) in some documents, means the group that provides direct oversight and monitoring of the DAP, including development and approval of IDAPPS, DAP planning, funding decisions and the maximization of all revenue sources, utilization management, and the efficient discharge of individuals from state hospitals. The RUMCT includes representatives of the participating CSBs and state hospital and involved private providers. This team also is responsible for monitoring the use of other regional funds or programs, such as LIPOS or crisis stabilization. While not members of the RUMCT, Department central office staff frequently participates in RUMCT meetings.

State Hospital means a mental health hospital operated by the Department of Behavioral Health and Developmental Services. For purpose of this manual, state hospital does not include the Hiram Davis Medical Center, the Commonwealth Center for Children and Adolescents, or the Virginia Center for Behavioral Rehabilitation.

Utilization Review (also known as “scrubbing”) means the process in which the RUMCT reviews active IDAPPs and adjusts services, costs, and revenues to more accurately reflect the changing needs of supporting the individual in the community. While individual needs change and IDAPP expenses may be more or less than the initial projection, these reviews often result in the identification of unneeded funds that may be used for IDAPPs to support discharges of other individuals from state hospitals.

Discharge Assistance Program Administrative Manual 17 Appendix B: Model MOU

Partnership Region (insert number) CSBs and (insert name) State Hospital DAP MOU for FY (insert year).

This MOU, effective (date), is between participating CSBs and the State Hospital listed below.

• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating State Hospital

I. Purpose

The parties listed above enter into this MOU for the purpose of implementing the regional Discharge Assistance Program, hereafter referred to as the DAP. The DAP has three purposes:

• to serve discharged individuals currently receiving DAP services and transition them into non-DAP funded services and supports;
• to serve adults in state hospitals clinically ready for discharge requiring additional funding for community placement through discharge assistance funds.
• to fund start-up and ongoing costs for community services enabling hospital discharges.

This MOU establishes a uniform mechanism to manage, coordinate, monitor DAP services, IDAPPs, and resource utilization.

Discharge Assistance Program Administrative Manual 18 II. Scope of Work

A. Regional Management Group (RMG)

1. The participating CSBs and the participating State Hospital hereby establish a Regional Management Group, hereafter referred to as the RMG. The Executive Director of each participating CSB and the Director of the participating State Hospital shall each serve on or appoint one member of the RMG. The responsibilities of the RMG may be carried out by participating CSBs, the participating State Hospital, and/or the regional manager and support staff

1. Through the RMG, CSBs and Hospital shall select a regional model from Appendix E, describe its operation in this MOU, and comply with Appendices E and F.
2. The RMG shall manage DAP and coordinate funding, including allocating state DAP funds among CSBs.

1. The RMG shall establish and oversee the RUMCT to manage all DAP aspects.

1. The RMG may authorize the employment of a regional manager and the necessary staff to administer the DAP with funds drawn from existing regional resources. The RMG shall identify the job description of all staff and identify which CSB will provide supervision of the regional manager and staff.

1. The RMG shall coordinate and monitor DAP service utilization using data from the RUMCT and regional manager.

1. The RMG shall perform duties assigned in this MOU or by participating entities.

1. Department Central Office staff, non-members of the RMG, shall access all documents, including IDAPPs, and may attend RMG meetings and activities.

Discharge Assistance Program Administrative Manual 19 B. Regional Utilization Management and Consultation Team (RUMCT) The RMG shall establish a Regional Utilization Management and Consultation Team, hereafter referred to as the RUMCT, to manage all aspects of the DAP. The RUMCT shall ensure compliance with the requirements outlined in the DAP Administrative Manual and IDAPP submission and review.

The RUMCT shall consist of representatives from participating CSBs in the region, the participating State Hospital, and others as may be appointed by the RMG, such as the regional manager. The RUMCT shall be composed of:

• (insert name, title/position, and organization, e.g., name of CSB)
• (insert name, title/position, and organization, e.g., name of CSB)
• (insert name, title/position, and organization, e.g., name of CSB)
• (insert name, title/position, and organization, e.g., name of CSB)
• (insert name, title/position, and organization, e.g., name of CSB)
• (insert name, title/position, and organization, e.g., name of CSB)
• (insert name, title/position, and organization, e.g., name of CSB)

RUMCT meets at least monthly or more as needed for funding, census, or case reviews. Minutes are recorded at each meeting.

1. Review IDAPP proposals to ensure services are appropriate, effective, efficient, and meet individual clinical needs.
2. Jointly review all IDAPPs quarterly or more often to ensure service appropriateness, implementation, accurate financial reporting, and address service reductions or discontinuations.
3. Review individuals on the EBL to identify or recommend community services and funding; RUMCT will inform RMG of results and actions.
4. Facilitate, upon request, resolution of discharge barriers or community retention issues.

Discharge Assistance Program Administrative Manual 20

1. identify opportunities for two or more CSBs to work together to develop programs or placements that would permit individuals to be discharged from the state hospital participating in the regional partnership more expeditiously.
2. Review and endorse new IDAPPs (ongoing or one-time) via in person, email, or other technology.

This review process may revise IDAPPS, adjust, or redistribute DAP funds.

The regional manager, in collaboration with the participating CSBs, shall maintain a current database on all individuals receiving DAP-funded services. This database shall include electronic copies of all on-going or one-time IDAPPs. All IDAPPs shall be submitted using the Department approved form. The regional manager shall maintain automated back-up data transferable by encryption on all regional DAP activities.

Non-RUMCT Central Office staff shall access all RUMCT documents, including IDAPPs, and may attend meetings per community services provisions.

RUMCT.

III. DAP Financial Management (Modify with details of the regional program model chosen by the RMG.)

A. Allocation and Re-allocation of State DAP Funds

1. The Department allocates all mental health DAP funds regionally; former local DAP funds are now part of regional funds.

1. All DAP funds are restricted; CSBs must track and report expenditures separately in CARS and DAP reports, and cannot use funds for non-DAP purposes.

B. Disbursement of State DAP Funds The Department disburses regional DAP funds directly to the CSB acting as the fiscal agent for the region, as part of the regular semi-monthly CSB payments. The fiscal agent CSB administers these funds and distributes the funds for payment of delivered services and/or as determined by the RMG and as described in the regional MOU.

The CSB acting as the fiscal agent for the region shall receive payments of state funds from the Department for the DAP through its community services performance contract.

The fiscal CSB must fund approved IDAPPs to ensure their continuation.

Discharge Assistance Program Administrative Manual 21

C. Allowable Uses of State DAP Funds

1. DAP funds shall be used exclusively to serve discharged individuals transitioning to non-DAP services, support clinically ready adults requiring funding for community placement, and fund start-up or ongoing community services.

1. When no other sources are available, DAP funds may support approved services meeting individual needs in the most integrated, least restrictive settings.

1. Regions and participating CSBs typically use DAP funds to support the costs of approved ongoing or one-time IDAPPs. Use of DAP funds to create or expand community infrastructure in order to facilitate state hospital discharges requires prior approval from DBHDS

1. Regions shall prioritize the use DAP funds for individuals who have the greatest tenure on the EBL. However, this requirement is subject to the availability of funds and the overall ability to facilitate discharge.

1. Regions may use DAP funds to pay for medications as part of an approved IDAPP once other sources of support for medications have been exhausted. These sources include mental health state funds previously used for the Department’s community resource pharmacy and now allocated to CSBs for the same purpose, indigent care programs offered by most pharmaceutical manufactures, and Medicaid. Medicare Part D, the prescription drug benefit, requires true out of pocket costs. DAP funds may not be used on behalf of a Part D beneficiary, (e.g., assistance with copayments).

DAP funds do not meet the federal definition of incurred out of pocket costs required by Part D.

1. Regions cannot use DAP funds to serve individuals receiving state-funded PACT, except for direct residential placement costs such as rent or housing subsidies or other non-PACT provided services.

1. Regions cannot use DAP funds for individuals already living in the community who were previously discharged or previously received DAP services but who no longer have an IDAPP authorized by the RUMCT.

Discharge Assistance Program Administrative Manual 22

1. Regions cannot use DAP funds to support CSB staff positions or other CSB programs or services that are unrelated to specific individual needs as reflected in on-going IDAPPs. This includes CSB hospital liaison positions.

1. Regions cannot approve the use of DAP funds as direct income to any individual receiving DAP services. DAP funds are not individual entitlements and cannot be used to provide personal income to individuals receiving DAP services.

10. For non-Medicaid individuals receiving State Plan or Clinic services, costs must not exceed the usual cost or frequency.

D. Maximizing Other Funding and Revenue Sources: The region and participating CSBs must use DAP funds as the funding source of last resort for all IDAPPs. The RMG, RUMCT and the participating CSBs shall ensure that other funds such as Medicaid payments, other appropriate state general funds, fees paid by individuals receiving services, and other third-party funding sources are used to offset the costs of approved IDAPPs to the greatest extent possible so that state DAP funds can be used to discharge the greatest number of individuals from state hospitals. The costs of an IDAPP must be adjusted to reflect other sources of funding or revenues that are identified and obtained. This shall be documented in records maintained by the CSB and the regional manager and in reports submitted to the Department.

E. Unexpended State DAP Funds

1. Generally, the use of unspent DAP funds is governed by Appendix C of the CSB Administrative Requirements. However, all DAP funds are restricted and any DAP funds that remain unspent at the end of the fiscal year in which they were disbursed by the Department shall remain restricted funds. Consequently, those unspent DAP funds cannot be used for other purposes and shall be used by region and participating CSBs to defray the costs of current IDAPPs before current fiscal year state DAP funds are used. Unspent balances above 10% of the annual allocation of state DAP funds that are not used within the fiscal year in which they were allocated are subject to recovery by the Department through payments to the Department by the region holding the balances, reductions in current disbursements to the region holding the balances, or reductions in allocations of DAP funds to the region (unless the Department determines that there are extenuating circumstances which justify an exception).

1. The RMG may approve the use of any of its unexpended DAP fund allocations during the current fiscal year that resulted from delays in discharges, re-hospitalization or incarceration of an individual receiving DAP services, reductions in services in approved IDAPPs, termination of an IDAPP, changes in allocations among CSBs, or other balances including year-end balances from previous fiscal years. Unexpended allocations and balances (“onetime funds”) shall be used for the following priorities: Discharge Assistance Program Administrative Manual 23 a. for one-time IDAPPs to support the discharge of individuals on the state hospital EBL; b. for addressing the one-time needs of individuals with approved IDAPPs; c. for transitional costs of individuals determined to be NGRI as part of the privileging process (these individuals might not be rated clinically ready for discharge due to their privileging level, but may need DAP funds to support community passes as part of the process) or for other individuals in state hospitals with documented clinical needs for transitional services and supports in order to be discharged; d. when needed, to cover the cost of obtaining a guardian for an individual in a state hospital. This process may begin prior to the individual becoming clinically ready for discharge e. for temporary funding to supplement an IDAPP while the CSB obtains benefits for an individual; or f. for developing regional infrastructure to enable the discharge of individuals in state hospitals, such as residential resources or other community placements.
2. If a region expends less than 90% of ongoing DAP funds or obligates less than 95%, the Department may transfer unspent funds to other regions unless justified by extenuating circumstances.

IV. Census Management (Modify with details of regional service operations selected by the RMG.)

A. Discharge Planning: Participating CSBs shall develop the discharge plan in consultation with the individual, guardian or authorized representative, and the state hospital treatment team. This plan describes the specific community mental health, developmental, or substance abuse, employment, health, educational, housing, recreation, transportation, legal, and advocacy services and supports needed by the individual following an episode of hospitalization and identifies the providers that have agreed to provide these services to the individual.

B. Extraordinary Barriers to Discharge List (EBL) Monitoring and Reporting: The participating CSBs through the RUMCT and regional manager shall monitor the EBL and the Discharge Ready list at the state hospital serving the region monthly to track individuals for whom they are the case management CSBs to ensure the individuals are discharged as soon as possible.

Discharge Assistance Program Administrative Manual 24

C. Development of Individualized Discharge Assistance Program Plans (IDAPP):

1. The case management CSB, the individual being discharged, his/her guardian or authorized representative, and the state hospital treatment team shall determine the most appropriate services and placement in the community for the individual that are consistent with his or her choices to the greatest extent possible.
2. DAP services and supports must be documented on the IDAPP, and the IDAPP must be consistent with the individual’s preferences and choices to the greatest extent possible.
3. All individuals with on-going IDAPPs must receive case management services or documented CSB monitoring. This shall be documented monthly in progress notes by the case management CSB and used to provide updates during DAP “scrubbing”.
4. The IDAPP shall be completed and endorsed by all relevant parties. The case management CSB must submit a brief narrative describing the individual needs and proposed plan, identified placement, projected discharge date, and an explanation of all revenues and costs with all new or renewing IDAPPs. New IDAPPs must identify all the services the individual needs to successfully transition to the community, the providers who have agreed to provide the services, and a projected discharge date.

IDAPP must show all revenues by source and projected expenses.

1. When DAP funds are used for community infrastructure, the planned use, costs, services/supports, and number of individuals served must be submitted to DBHDS for prior approval. The regional manager shall then submit an annual accounting of expenditures, service units/types, and individuals served.

D. Monitoring of IDAPPs: The RUMCT or its designee shall review at least quarterly and more frequently when there is a shortage of regional DAP funds, the implementation of all IDAPPs to ensure the effective and efficient utilization of the DAP funds. The RUMCT shall develop a process of communication to ensure that the RMG is informed of the utilization review activities.

If the case management CSB is not able to implement an approved IDAPP for the individual within 30 calendar days of his or her projected date of discharge, one of the following actions shall be taken within 30 calendar days following the projected date of discharge:

1. The region shall identify and discharge another individual who is on the EBL or who has been determined to be clinically ready for discharge and for whom DAP funding is appropriate for addressing the barriers to that individual’s discharge;
2. If not completed within 30 days, funds for the IDAPP revert to RUMCT for another discharge per DAP prioritization;

Discharge Assistance Program Administrative Manual 25

1. Should an individual who has been adjudicated Not Guilty by Reason of Insanity (NGRI) not be discharged within 30 days of the projected discharge date due to circumstances beyond the control of the individual, CSB and/or state hospital; the CSB shall send a memo to the RUMCT with an explanation of said circumstance.

Examples of these circumstance could include, but not limited to: IFPC and/or FRP revision requests, residential provider withdrawing acceptance for reasons not related to the individual’s behavior, the NGRI court’s delay in scheduling a conditional release hearing date, etc. The RUMCT shall make a decision whether to continue funding IDAPP based on the facts presented.

E. Rehospitalization: Upon occasion it may be necessary for DAP enrollees to receive in-patient psychiatric services or be incarcerated. Should this occur, the case management CSB will notify the RUMCT. The RUMCT then may select from the following options:

1. If the RUMCT approves a written request from the CSB, it will stop current payments and resume payments upon the individual’s discharge, if that date is within an agreed upon number of days not to exceed 90 days from the date of re-hospitalization in a state hospital;
2. If the CSB requests that re-hospitalization exceed 30 days and ongoing funds are needed for up to 90 days to maintain residence and services like guardianship, the RUMCT may approve necessary funds. Unspent funds shall be redistributed per manual; or
3. The CSB returns the state DAP funds, less year-to-date expenditures, for the unimplemented IDAPP to the RUMCT for redistribution.

Note: The cost of supporting a substitute individual shall not exceed the amount requested in the originally approved IDAPP unless funding is available and approved by the RUMCT.

Should the cost of services be less than originally requested, unexpended funds will be available to the RUMCT for redistribution in accordance with the provisions of this manual.

For all IDAPPs where the service provider is not the CSB of origin, that CSB shall develop a purchase of service agreement, memorandum of agreement, or other instrument consistent with the CSBs’ purchasing policies and procedures. All such instruments shall be maintained by the affected CSBs and available to the Department upon request.

V. Transfers of Individuals Between CSBs or Regions (Modify this section and insert applicable details in this section of the operations of the regional program model selected by the RMG.) If the individual, or with the consent of a guardian or an authorized representative, chooses to reside in a different locality after discharge from the state hospital, the CSB in the chosen locality becomes the receiving case management CSB and works with the original case management CSB, the individual, and the state hospital to effect a smooth discharge and Discharge Assistance Program Administrative Manual 26 transition to the community. The case management CSB of origin is responsible for the completion of the discharge plan and is expected to collaborate with the receiving CSB.

If an individual receiving DAP services decides to move to another CSB’s service area within the region, the receiving CSB will assume Case Management CSB responsibilities and shall be responsible for the appropriate reporting in CARS and CCS 3.

If an individual approved for DAP funds elects to reside outside of the DBHDS region of origin, it is understood that the respective regions and CSBs shall work collaboratively in addressing the individual’s preferences and needs. The following are examples of how this process applies: The receiving Region accepts the transfer of the IDAPP funds and assumes case management CSB responsibilities. Effective July 1, 2018, the transfer of DAP funds shall occur within six months of the individual being placed in the receiving Region. The receiving CSB shall then be responsible for the reporting required of the performance contract. The affected CSBs and regions shall notify the respective regional managers and the Department of any changes in case management CSB designation and request the fund transfer no later than 30 days post discharge or transfer. This transfer of DAP funds shall apply unless the Department determines that there are extenuating circumstances which justify an exception.

If additional DAP funds other than those provided through the original IDAPP are required to support the individual in the new setting after transfer, the region holding the IDAPP funds for the individual shall provide the additional funding based on approval of a revised IDAPP.

For individuals outside their original region, DAP funds transfer to the new region within six months of discharge.

Individuals adjudicated NGRI and placed outside their case management CSB area may have specific conditions in their Conditional Release Plan related to their case management CSB or residence.

Under these conditions, the CSB may choose (or be required) not to reallocate funds and oversight to the new region, in which case the CSB and region of origin shall remain the case management CSB and region of record. The case management CSB is then responsible for all required reporting under the performance contract and conditional release plan.

VI. Reporting: Modify this section to include details of the regional program model selected by the RMG.

A. Performance Contract Requirements:

Participating CSBs and the regional manager shall comply with all requirements in Exhibit C of the community services performance contract, including reporting.

The regional manager shall submit the quarterly summary of IDAPPs to the Department in a format developed by the Department in consultation with regional managers and Discharge Assistance Program Administrative Manual 27 designated members of VACSB. Quarterly reports will document year-to-date information about ongoing and one-time IDAPPs, including data about each individual receiving DAP services and the amounts of DAP funds approved for each IDAPP (if requested), the total number of IDAPPs that have been implemented, and the total DAP funds obligated for these IDAPPs. The first and third quarter reports are due thirty (30) days following the end of the quarter. The second and fourth quarter reports are due forty-five (45) days after the end of the quarter. It is the participating CSBs’ responsibility to provide the regional manager with accurate information related to actual costs and other revenue to ensure the accuracy of reports.

B. Community Consumer Submission 3 (CCS 3) Reporting:

The case management CSB is responsible for ensuring that the required information about the individual, his/her type of care (Consumer Designation Code for DAP) and the services received are entered in their information system and reported to the Department through the extraction by the CCS 3. CCS 3 submissions must satisfy the requirements in Exhibit I of the performance contract. These requirements apply to all IDAPPs implemented with DAP funds.

CSBs shall assign a 910 Consumer Designation Code only to individuals with ongoing IDAPPs, including ongoing plans that are supported through extended use of onetime funds. Additional information about assigning, initiating, and ending consumer designation codes and about all other aspects of reporting data through the CCS is available in the current Community Consumer Submission 3 Extract Specifications, which is available at http://www.dbhds.virginia.gov/OCC-default.htm.

C. Community Automated Reporting System (CARS) Reporting: The case management CSB responsible for directly providing or purchasing the services in an individual’s IDAPP shall reflect, account for, and report the actual revenues and actual expenses associated with the services in the IDAPP through the mid-year and end of the fiscal year CARS reports. Reports must satisfy the requirements in Exhibit I of the performance contract. These requirements apply to all IDAPPs implemented with DAP funds.

VII. Review and Evaluation

A. Utilization Review: The participating CSBs and state hospital in each region shall develop and implement a utilization review process for all IDAPPs and DAP supported programs. At a minimum, this process (known as “scrubbing”) will include a review of the current IDAPP, services being received or provided, confirmation that the individual’s has applied for and/or is receiving all eligible benefits or entitlements (e.g., Medicaid, insurance, SSI/SSDI, or other sources), amounts of other income received, and confirmation of the residential placement during the quarter.

The RUMCT or subcommittee shall conduct quarterly reviews of IDAPPs for service appropriateness, compliance, and events like re-hospitalizations or terminations. If funds are insufficient for new requests, existing plans are reviewed monthly or more often.

B. Department Reviews: The Department shall regularly monitor the performance of the regions’ management of the DAP as well as the CSBs’ implementation of IDAPPs. Pursuant to sections 6.f and

1. Under the Community Services Performance Contract, the Department may conduct ongoing utilization reviews and analyze data on individuals, services, re-hospitalizations, transitions, revenue, expenditures, outcomes, and performance to ensure DAP effectiveness and efficiency.

The Department shall include the financial and programmatic operations of the DAP as part of its regular CSB Review, which is conducted by multidisciplinary teams including Department fiscal and program staff.

C. Performance Measures: The RUMCT and RMG shall monitor the performance measures established by the Department in the DAP Manual by receiving reports at least quarterly from the regional manager on the DAP’s achievement of the measures. The RMG and participating CSBs shall take actions in a timely manner to address unsatisfactory performance on any measure.

VIII. Term of the MOU

This MOU shall be in effect for one year beginning on July 1, (enter year) and ending on June 30, (enter year). This MOU shall automatically renew for four additional 12-month periods unless terminated in writing as provided below.

IX. Termination of the MOU

Each of the parties is authorized to terminate this MOU if it determines that another party has violated a material term of the MOU. Each of the parties may terminate its obligations under this MOU by giving each of the other parties 60 days written notice. If one or more of the parties gives notice of its desire to terminate the MOU, the parties shall confer to determine whether the DAP may continue in effect without the participation of the terminating party or parties. If the DAP is terminated or the Department reduces state funding for the DAP, participating CSBs shall not be required to continue to provide services that are the subject of this MOU. In the event funding is terminated or reduced, continued access to community services for individuals currently receiving DAP services shall be governed by the existing community services performance contract, CSB policies, and other procedures for the provision of services.

Discharge Assistance Program Administrative Manual 29 X. General Terms and Conditions

A. The parties and the regional manager agree they shall comply in their implementation of the DAP with all applicable provisions of state and federal law and regulations, the provisions and requirements of the DAP Manual, the current community services performance contract, the Discharge Protocols for Community Services Boards and State Hospitals, the current Human Rights and Licensing Regulations, and applicable State Board policies. Applicable provisions of the current community services performance contract include Exhibit C and Appendix E: Regional Program Operating Principles and Appendix F: Regional Program Procedures that are in current Core Services Taxonomy.

If there are any conflicts or inconsistencies between any provisions of this MOU and the current community services performance contract, applicable provisions of the contract shall control. However, this MOU may modify applicable provisions in Appendix F of Core Services Taxonomy to reflect the unique nature of the DAP.

B. Nothing in this MOU shall be construed as authority for any of the parties to make commitments that will bind the other parties beyond the scope of this MOU.

Parties shall not assign, sublet, or subcontract work related to this MOU without prior written consent.

C. No alteration, amendment, or modification in the provisions of this MOU shall be effective unless put in writing, signed by the parties, and attached hereto.

D. Nothing in this MOU is intended to, nor does it create, any claim or right on behalf of any individual to any services or benefits from any of the parties.

XI. Privacy of Personal and Health Information: For this section, parties include the regional manager.

Parties agree to keep PHI and PII confidential, disclosing only as permitted by law, including HIPAA, Virginia Health Records Privacy Act, and relevant regulations and policies.

Parties may disclose PHI, PII, or confidential info to fulfill responsibilities under this MOU, including service coordination and management, under 45 C.F.R. § 164.512(k)(6)(ii) and contract provisions.

C. In carrying out their responsibilities under this MOU, the parties may use and disclose PHI, PII, or other confidential information to one another to perform the functions, activities, or services specified in this MOU on behalf of one another, including utilization review, financial and service management and coordination, collaboration and sharing of information relative to discharge planning and clinical case consultation. In so doing, the parties and the regional manager agree to:

1. Not use or disclose PHI, PII, or confidential info except as permitted by this MOU or law;

1. Use safeguards to prevent unauthorized use or disclosure of PHI, PII, or confidential info as permitted by this MOU;

1. Report to other parties any unauthorized use or disclosure of PHI, PII, or confidential info of which they become aware;

1. Impose the same requirements and restrictions of this MOU on subcontractors and agents receiving PHI, PII, or confidential info to perform services or functions for the parties;

1. Provide access to PHI, PII, or confidential info in designated records to other parties or individuals as required by 45 CFR 164.524 or the community services contract, in the specified time and manner;

1. Make PHI, PII, or confidential info available for amendment and incorporate amendments upon request of other parties;

1. Document and provide disclosures of PHI, PII, or confidential info as needed for individual disclosure accounting per 45 CFR 164.528;

1. Make internal practices, books, and records related to PHI, PII, or confidential info available to HHS Secretary for compliance review per 45 CFR Parts 160 and 164, subparts A and E;

1. Implement safeguards to protect electronic PHI, PII, or confidential info as required by HIPAA Security Rule, 45 C.F.R. Parts 160, 162, and 164, and the community services contract;

Ensure agents or subcontractors receiving electronic PHI, PII, or confidential info implement safeguards.

Report any security incidents to other parties.

At MOU termination, if feasible, return or destroy all PHI, PII, or confidential info; if not, extend protections and limit uses/disclosures.

D. Each of the parties may use and disclose PHI, PII, or other confidential information received from the other parties, if necessary, to carry out its legal responsibilities and for the proper management and administration of its business. Each of the parties may disclose PHI, PII, or other confidential information for such purposes if the disclosure is required by law, or if the party obtains reasonable assurances from the person to whom the PHI, PII, or other confidential information is disclosed that it will be held confidentially, that it will be used or further disclosed only as required by law or for the purpose for which it was disclosed to the person, and that the person will notify the party of any instances of which it is aware in which the confidentiality of the information has been breached

E. All parties shall encrypt transmissions of DAP-related information and data about individuals receiving DAP services, including all forms and reports containing PHI PII, or other confidential information, in a manner specified in the community services performance contract and pursuant to the applicable provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) and subsequent implementing regulations.

Discharge Assistance Program Administrative Manual 32

IN WITNESS WHEREOF, the parties have executed this agreement and intend to be bound.

________________________________________________ __________________ (type name of executive director under signature line)

Date Executive Director, (insert name of CSB)

________________________________________________ _________________ (type name of executive director)

Date Executive Director, (insert name of CSB)

________________________________________________ _________________ (type name of executive director under signature line)

Date Executive Director, (insert name of CSB)

________________________________________________ _________________ (type name of executive director under signature line)

Date Executive Director, (insert name of CSB)

________________________________________________ __________________ (type name of executive director under signature line)

Date Executive Director, (insert name of CSB)

________________________________________________ __________________ (type name of executive director under signature line)

Date Executive Director, (insert name of CSB)

________________________________________________ __________________ (type name of executive director under signature line)

Date Executive Director, (insert name of CSB)

________________________________________________ ________________ (type name of state hospital director)

Date Director, (insert name of state hospital)

33 Appendix C: Clinical Readiness for Discharge Rating Scale

Treatment teams shall rate all individuals' discharge readiness in state hospitals at least monthly using the scale.

1. Clinically Ready for Discharge: The individual meets any of the following criteria. a. has met treatment goals and does not need inpatient psychiatric treatment b. NGRI with up to 48 hour privilege level c. NGRI under a temporary custody order and at least one forensic evaluator has recommended conditional or unconditional release and there is a pending court date d. NGRI on revocation status and the treatment team and CSB recommend conditional or unconditional release and there is a pending court hearing

1. Almost Clinically Ready for Discharge: The individual meets any of the following criteria. a. needs additional inpatient care to fully address clinical issues and/or there is concern about adjustment difficulties b. can take community trial visits to assess readiness for discharge; may have the civil privilege level to go on overnight temporary visits c. resistant to discharge and refuses to engage in discharge process d. NGRI with unescorted community visits privilege

1. Not Clinically Ready for Discharge: The individual meets any of the following criteria. a. participates in treatment (engaged, adherent with medications, groups. etc.) but unable to function independent of 24 hour supervision in an inpatient psychiatric setting b. not yet able to take independent passes or take trial passes to a supervised placement but may have unescorted grounds privileges if available at the hospital c. NGRI and does not have unescorted community visits privilege

1. Significant Clinical Instability Limiting Privileges and Engagement in Treatment: The individual meets any of the following criteria. a. not psychiatrically stable b. requires constant 24 hour supervision in an inpatient psychiatric setting c. presents significant risk and/or behavioral management issues d. acutely psychotic

Notes: Discharge planning begins on admission and should be active throughout the individual’s hospitalization independent of his or her clinical readiness for discharge rating. An individual may be clinically ready for discharge before the rating is formally completed.

34 Appendix D: Community Services Performance Contract Exhibit C: Discharge Assistance Program Requirements

The Department and CSB will implement requirements for managing regional DAP funds to improve monitoring, accountability, reduce individuals on hospital EBLs, and maximize community discharges.

1. The Department will collaborate with VACSB, CSBs, and regional managers to develop clear criteria for identifying individuals benefiting from DAP, acceptable fund uses, and standard data terminology for reporting.

1. The CSB shall comply with the current Discharge Assistance Program Manual issued by the Department, which by agreement of the parties is hereby incorporated into and made a part of this contract by reference. If there are conflicts or inconsistencies between the Manual and this contract, applicable provisions of the contract shall control.

1. Regional DAP funds shall be managed by the RMG and RUMCT, with CSB participation, per Appendices E and F of the Core Services Taxonomy.

1. The CSB, via RMG and RUMCT, shall maximize Medicaid and other funds to offset IDAPP costs, enabling more DAP services and reducing EBLs.

1. The regional manager shall submit mid-year and year-end reports to the Department, showing actual expenditures for ongoing and one-time IDAPPs and unspent funds, in a format developed by the Department.

1. If CSBs cannot expend 90% and obligate 95% of regional DAP funds by year's end, the Department may transfer funds to other regions unless extenuating circumstances justify an exception.

1. The regional manager shall continue submitting quarterly IDAPP summaries to the Department, in a format developed by the Department, showing year-to-date data on ongoing IDAPPs.

Includes data on each individual DAP recipient, approved funds per IDAPP, total IDAPPs implemented, and projected net regional DAP funds obligated.

1. The Department may conduct utilization reviews of the CSB or region at any time to verify effective use of DAP funds and implementation of approved IDAPPs.

36 Appendix E: DAP Performance Measures

Data Performance Measures Data Sources for Measures

State Hospital Bed Days Used by DAP-Enrolled Individuals Before and After Enrollment Over Equal Periods.

CCS 3 Care and Service Records

AVATAR

Readmission to a State Hospital within 30 and 180 Days After Enrollment in DAP Percent of 30 and 180 Day State Hospital Readmissions by Individuals Enrolled in DAP ÷ Percent of 30 and 180 Day State Hospital Readmissions by All Adults During the Reporting Period CCS 3 Type of Care and Service Records

AVATAR

Admission to a State Hospital After Release From a DAP Episode of Care Individuals Admitted to a State Hospital Within 60 Days of Release From a DAP Episode of Care ÷ Total Number of Individuals Released From DAP During the Reporting Period CCS 3 Type of Care and Service Records

AVATAR

Individuals Discharged to DAP From a State Hospital Extraordinary Barrier List (EBL) State Hospital EBL Individuals Discharged to DAP ÷ All Individuals Newly Enrolled in DAP During the Reporting Period CCS 3 Type of Care and Service Records

AVATAR

State DAP Funds Used ÷ Allocated Funds per Region, quarterly reports.

CARS

Housing Stability (deferred) Number of Individuals in DAP with No More Than One Housing Move ÷ Total Number of Individuals in DAP During an Annual Reporting Period CCS Consumer Record and Type of Care Record

37 Appendix F: Notes and Sources for DAP Performance Measures

1. All measure data can be displayed statewide, regionally, and by individual CSB.
2. Number of individuals receiving DAP services is derived from CCS 3 Type of Care (910 Code) and Service records.
3. Number of individuals completing a DAP episode is derived from CCS 3 Type of Care (910 Code) and care end date.
4. Number of individuals admitted to a state hospital is derived from AVATAR.
5. Number of state hospital beds is derived from AVATAR.
6. Number of individuals enrolled in Medicaid: CCS 3 Consumer Record (insurance type and Medicaid number) and quarterly DAP reports.
7. Number of individuals for whom Medicaid payments have been received is derived from quarterly DAP reports.
8. Amount of state DAP funds allocated is derived from CARS reports.
9. Amount of state DAP funds expended is derived from Quarterly DAP Reports. 10. Changes in residence are derived from the CCS 3 Consumer Record (Data Element 88).

DBHDS SDMA Draft Sample Page 1 of 47 DBHDS Office of Provider Development Supported Decision-Making Agreement Draft Sample Effective: July 15, 2022 Purpose: This document contains a draft sample of Virginia’s Supported Decision-Making Agreement (SDMA), which was mandated as part of the Department of Behavioral Health and Developmental Services’ powers and duties related to supported decision-making agreements in § 37.2-314.3 of the Code of Virginia by the 2021 Special Session I of the Virginia General Assembly with the passing of House Bill 2230. Instructions on how to complete the agreement and optional discovery tools are included. SDMAs provide a way for individuals to document when they want support with making decisions, how they want to receive that support, and who they want to support them. The decision maker retains the right to make all final decisions.

SDMAs are not legally binding and serve as a less restrictive alternative to substitute decision-making, such as legal guardianship. The Code of Virginia § 37.2-314.3 defines individuals entering into a SDMA as “principals,” however in the Virginia SDMA draft and all supplemental documents, the individual is referred to as the “decision maker.” Those from whom the individual identifies as wanting support are known as “supporters.” Following the implementation of the Virginia SDMA and educational campaign, data will be collected and presented along with recommendations in the form of a report to the Virginia General Assembly by November 1, 2022.

Regulations addressed: The Code of Virginia § 37.2-314.3 defines supported decision-making agreements as “an agreement between a principal and a supporter that sets out the specific terms of support to be provided by the supporter, including (i) helping the principal monitor and manage his medical, financial, and other affairs; (ii) assisting the principal in accessing, obtaining, and understanding information relevant to decisions regarding his affairs; (iii) assisting the principal in understanding information, options, responsibilities, and consequences of decisions; and (iv) ascertaining the wishes and decisions of the principal regarding his affairs, assisting in communicating such wishes and decisions to other persons, and advocating to ensure the wishes and decisions of the principal are implemented.” The use of supported decision-making and supported decision-making agreements in Virginia aligns with Human Rights Regulations regarding Participation in Decision Making and Consent [12VAC35-115-70] as “each individual has a right to participate meaningfully in decisions regarding all aspects of services affecting him.” SDMAs help ensure that the decision maker actively participates in decisions involving all aspects of their life and is supported in exercising their legal, civil, and human rights.

Guidance Document DD 06 DBHDS SDMA Draft Sample Page 2 of 47 Instructions Instructions for how to complete Virginia’s Supported Decision-Making Agreement template.

Commonwealth of Virginia: Supported Decision-Making Agreement Page 1 of 6 How to Fill Out My Supported Decision-Making Agreement Step 1: Decide if a supported decision-making agreement is right for you.

A supported decision-making agreement might be right for you if you can make decisions about your life on your own, or with some help from people you trust. You must be 18 years old or older and legally be able to make your own decisions. Typically, if you have a court-appointed legal guardian or conservator you have been declared incapacitated in some, if not all, parts of your life. This means that you may not have the legal right to make certain decisions. A supported decision-making agreement is not a legal document a judge would order in court to give you, but people should follow any choices you make, as you have the right to make all final decisions.

Step 2: Decide when you want support.

You might want support in some parts of your life, but not in others, and that is okay.

You can use the When Do I Want Support? tool to help you think about choices in your life. For each choice or activity, think about if you:  Can do this on your own.  Can do it with help.  Need someone to do it for you.

The choices and activities listed on this tool are the same ones listed on the Commonwealth of Virginia Supported Decision-Making Agreement and are listed in the same order on both forms.

Step 3: Decide what kind of support you want.

Support (help) can look different for everyone and can be different for each choice or activity. Think about the choices and activities you can do with help and what help looks like for you. You can use the What Kind of Support Do I Want? tool to help think about and write down the different types of support you might want.

Step 4: Decide who you want to support you.

Supported decision-making agreement are made up of supporters and decision makers. You are the decision maker and the people you select to help you are the supporters. You can choose anyone you want to be your supporter and you can choose to have many supporters. Some supporters might help you with one thing and others might help you with several things. The decision is up to you.

DBHDS SDMA Draft Sample Page 3 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Page 2 of 6 You can also choose someone to be a supporter and your supported decision-making facilitator. This person helps you make sure that the agreement is working and everyone is doing their part. You do not have to have a supported decision-making facilitator if you do not want one.

When thinking about who you want as a supporter, think about people that you trust and that know what you want and do not want in your life. You can use the Relationship Map tool to help you think about and write down people who help you and might be your supporters.

Step 5: Fill out your supported decision-making agreement.

Ask the people you want to be your supporters to meet with you. Talk with them about the choices and activities you can do with help and what kind of help (support) you want. You can even show them your When Do I Want Support? and What Kind of Support Do I Want? tools to help with this conversation.

Read through the Supported Decision-Making Agreement with your supporters starting on the first (1) page and fill out each question. You can fill out (write) the information in the agreement yourself or have someone you trust help you fill it out. It is okay to ask questions if you do not understand something.

On the first (1) page, your name goes on the line that asks for the “decision maker.” Then write the best way for someone to contact you. This could be your email address, cell phone number, home phone number, or something else. Next is the “initial effective date of the agreement”. This is the date when you first fill out and sign this form with your supporters. The last part of page 1 is where you can point out if you have any other types of support. These include:  Durable Power of Attorney- A document that tells people who you want to help make decisions for you if you are not able to tell people what you want on your own due to being sick or injured.  Advance Medical Directive- A document that tells people who you want to help make decisions about your health care for you if you are not able to tell people what you want on your own due to being sick or injured. It can also tell your doctors and people you trust what kind of medical care you do want, if you need it.  Financial Fiduciary- A person who is responsible for managing your money.

There are many different types of fiduciaries: Social Security Representative Payee, Department of Veterans Affairs VA Fiduciary, a Trust, your designee under a Power of Attorney, etc.

DBHDS SDMA Draft Sample Page 4 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Page 3 of 6  HIPAA Release Form- A form that tells your doctors who you say it is okay to let see notes (records) about your doctor’s appointments and health information.  Educational Release Form- A form that tells your school who you say it is okay to let see notes (records), attend meetings, and help you make decisions about your school services. You can use the form provided or one provided by your school. There are also other ways to get support with decisions about your education such as an Educational Power of Attorney.  Other- Any other documents that tell other people who the people are that help you and how they help you.

If you do have other types of support, write a check () whether or not you are attaching a copy of the document to our Supported Decision-Making Agreement.

Pages 2-18 list nine (9) life areas where you might make choices. These include:

1. Health and Personal Care,
2. Friends and Partners,
3. Money,
4. Where I Live and Community Living,
5. School and Education,
6. Working,
7. My Rights and Safety,
8. Meeting and Talking with My Supporters, and
9. Other- The life area of Other lets you write in other choices and activities you want help with or those that you do not want help with that are not listed in any of the other life areas.

For each life area, check () whether you do or do not want help. If you answer that you “do not want help” in a life area, you do not need to answer any more questions for that life area and you can go to the next one.

If you do want help with this life area, fill out the name, relationship (for example, mom, dad, teacher, sister, friend, doctor, etc.), address, email address, and phone number of your supporters for that life area. Then write “Y” for yes or “N” for no next to each sentence if you want that support. Reminder: These are the same sentences from the When Do I Want Support? tool and are listed in the same order.

DBHDS SDMA Draft Sample Page 5 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Page 4 of 6 For each sentence that you answer “Y” to, check () whether you want all of the supporters listed above to help you or just some of the supporters. If not all of the supporters, write the names of the supporters you want to help next to “Only Supporters Listed Here”.

For each life area, you have the option to write additional things you want help with, as there might be choices and activities not listed. You can also write things that you do not want your supporters to help you with or do for each life area.

Page 19 is the Agreements page. This is the page that you and your supporters sign stating that you all agree to the information written in the Supported Decision-Making Agreement. Make sure you and your supporters read and understand the Agreements page before signing. Remember, it is okay to ask questions if you do not understand something. If you have more than three (3) supporters, you can print the Agreements page again so that the other supporters can sign.

Do not fill out the grey box at the bottom when you are first creating your Supported Decision-Making Agreement. The grey box is the “Cancellation of Supported Decision-Making Agreement”. You fill this out and sign when you no longer want a Supported Decision-Making Agreement.

Page 20 gives you the option to choose a supported decision-making facilitator. This person helps you make sure that the agreement is working and everyone is doing their part. They can help you schedule meetings and talk with your other supporters, like the things listed in area 8. Meeting and Talking with My Supporters. The supported decision-making facilitator might be a supporter that you trust with helping you with many decisions or they might not be one of your supporters. You do not have to have a supported decision-making facilitator. It is your choice.

Page 21 gives you the option to have a notary sign and stamp your Supported Decision-Making Agreement. A notary public is someone who can confirm that everyone signed the agreement. You do not have to have a notary sign and stamp your agreement. It is your choice. You can find a notary public at most banks and local courts.

Sometimes people want to make changes to their Supported Decision-Making Agreement after it is done. You can write these changes on page 22, the Changes page. Write the date of the change, what the change was, and sign it. If you are adding a supporter, then the new supporter will need to sign also. You can do this up to three (3) different times on this same form.

There may also be times when you might not want someone to support you anymore.

When this happens, you can fill out page 23, the Cancellation page. Write the date of this change and the name(s) of the supporter you no longer want help from. Then sign the form. You can do this up to three (3) different times on this same form.

DBHDS SDMA Draft Sample Page 6 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Page 5 of 6 Step 6: My supported decision-making agreement is done. Now what do I do?

Once you have completed your Supported Decision-Making Agreement it is important to make sure that your supporters have copies of the agreement and other people who work with you have copies as well. This might include your doctors, case manager, school, service providers, or other people paid to support you. This way they know who you want support from, when you want support, and how you want support with different decisions. Make sure you keep a copy for yourself so that you know who to call when you need help or advice with different choices. It is important to that you and your supporters know that you cannot take your supporters to court if you do not like the advice they give you or they do not support you how you want to be supported (it is not legally binding). Remember, you make all of the decisions for yourself and you can change your supporters at any time.

Examples of People Using Supported Decision-Making Agreements Sam Sam is 18 years old. He has autism and uses words to communicate. He is in high school and has been learning job skills and about how to be a good employee while in school. Sam is considering graduating so that he can work and focus on his dream of being an actor.

Sam lives with his mother, father, and older sister, who visits when home from college.

Sam wants to live on his own in the nearby city after he graduates. He feels “the city is where stars are made.” Sam’s parents are nervous about Sam living on his own and making his own decisions because they worry he will be taken advantage of by others. Sam has never had to budget his money or pay bills and believes that everyone he meets is his friend.

Sam and his family decided to use a supported decision-making agreement to help Sam talk through decisions in the areas of life he needs more support. Sam is able to make his own decisions and keep his rights and independence. Sam and his family understand the benefits of Sam’s right to take risks and learn from them (dignity of risk).

Nikkia Nikkia is 25 years old and works part-time at Target helping people in the dressing rooms and rehanging clothes. Nikkia has cerebral palsy and an intellectual disability.

She has lived in her own apartment for the past three (3) years. Her apartment has space for her to move around easily when she uses wheelchair or walker. Nikkia has friends, neighbors, and coworkers that she trusts and they help her. Her family does not live close to her.

DBHDS SDMA Draft Sample Page 7 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Page 6 of 6 Nikkia talks, but some people who do not know her do not understand what she is saying. She does not like to use any type of technology to help her communicate, like an iPad or tablet.

One day Nikkia fell and had to go to the hospital. The doctors did not understand what she was saying and no one was able to help Nikkia answer questions. This made Nikkia think that she needed to write down the people she wants to help her if she gets sick or hurt. Nikkia created an advanced directive while at the hospital, but felt that she wanted to write down all of the people she wants to help her in her life.

Nikkia created a supported decision-making agreement with the people who agreed to be her Supporters. She gave copies of her supported decision-making agreement to her doctors, landlord, supervisor at work, and community case manager so that they all know what Nikkia wants help with, who she wants to help her, and how she wants to receive help.

Maria Maria is 35 years old and lives with her mother. Maria has an intellectual disability.

When she was a toddler she had several seizures which also caused her to have an acquired brain injury.

Maria does not use words to communicate, but does use sign language, pictures, and a program on her tablet.

During the day, Maria goes to a day support program in the mornings and then volunteers at the local SPCA shelter in the afternoons. Maria’s mother helps Maria with many things each day. She organizes Maria’s medications and reminds her when it is time to take them. She cooks for Maria and makes sure that Maria’s bedroom is clean.

Maria’s mother also helps Maria brush her teeth, brush her hair, and makes sure she is wearing clean clothes. Maria’s mother will drive Maria to places she wants to go and schedules the van when she cannot drive Maria.

Maria’s mother is aging and her other family members are worried about who will help Maria as her mother gets older. Maria’s mother never went to court to become her guardian. She felt she was able to care for Maria by being her Representative Payee, Power of Attorney, and Authorized Representative, which meant Maria could keep all of her rights. None of Maria’s other family members can be Maria’s legal guardian and Maria does not want to lose her rights to make her own decisions.

Maria, her mother, and her other family members decided to use a supported decision-making agreement to help Maria continue to make her own choices, but get help she needs when she wants it. Maria’s mother feels a sense of relief knowing that a supported decision-making agreement is in place.

DBHDS SDMA Draft Sample Page 8 of 47 DBHDS SDMA Draft Sample Supported Decision-Making Agreement Sample The following pages of this document pertain to Sam’s story, located on page 5 of the Instructions.

Page 9 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 1 of 23 This agreement should be read out loud or otherwise communicated in a way that is accessible and understandable to all parties. The form of communication should be appropriate to the needs and preferences of the person with a disability. A Supported Decision-Making Facilitator may be assigned to oversee this agreement, but is not required. Additionally, a notary may sign the agreement, but it is not required.

I, ______Sam Smith_________________, am the creator of this Supported Decision-Making Agreement which is all about me, and that makes me the “Decision Maker”. I made this agreement with my choices and have selected people that I trust to be my “Supporters”.

The people I select as my Supporters are the people who have agreed to help me understand and make choices.

My Supporters DO NOT make decisions for me. They give me information, advice, and other support so that I CAN make decisions for myself.

This agreement can be changed at any time. I can change it by crossing out words and writing my initials next to the changes, or I can change it by writing new information onto the form and writing my initials next to what I add. I will keep track of anything I add by filling out and signing the “Changes” page attached to this agreement. I will also write the names of any Supporters that I no longer want to support me on the “Cancellation” page attached to this agreement and sign it.

If I decide that I no longer want to have a Supported Decision-Making Agreement, I can fill out the Cancellation of Supported Decision-Making Agreement section at the bottom of the “Agreements” page attached to this document.

Name of Decision Maker: ____Sam Smith_________________________________________ Preferred Method of Contact (e.g. email address, phone number, how to contact you): Cell phone- 804-555-8000_______________________________________________________ Initial Effective Date of Agreement: ___05/01/2022__________ In addition to this Supported Decision-Making Agreement, I have the following forms of support: ___ Documents Attached/ ___ Documents NOT Attached ___ Documents Attached/ ___ Documents NOT Attached ___ Documents Attached/ _X_ Documents NOT Attached _X_ Documents Attached/ ___ Documents NOT Attached _X_ Documents Attached/ ___ Documents NOT Attached ___ Durable Power of Attorney ___ Advance Medical Directive _X_ Financial Fiduciary _X_ HIPAA Release Form _X_ Educational Release Form ___ Other: _________________ ___ Documents Attached/ ___ Documents NOT Attached (e.g. DBHDS Authorized Representative, Health Passport, Person Centered 1 Page Health Profile) DBHDS SDMA Draft Sample Page 10 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for:___Sam Smith___________ Page 2 of 24

1. Health and Personal Care I DO _X_ / DO NOT ___ want help with health and personal care decisions. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number *To add a new row, place cursor in bottom right box and press Tab.

These supporters may do these things: Write Y for “yes” or N for “no” to say if your Supporters can or cannot help with each option. _Y_ Get and look at my health care information, including seeing my private health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). A release is signed and attached to this agreement. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me choose when to go to the doctor. ____ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me make and keep my doctor and dentist appointments. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand and make medical choices in serious situations (for example, surgery, big injuries, mental or behavioral health crisis). _X__ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand and make medical choices in an emergency. _X__ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand and make medical choices in everyday situations (for example, check-up, getting medicine from the drug store). _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand my medications, help remind me about my medications, and assist me in getting and taking my medications. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me understand personal hygiene, help remind me about my personal hygiene, and help me with my personal hygiene. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me choose what to wear and help me get dressed, if needed. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ Paul Smith Dad 345 Main St., Richmond, VA 23235 345 Main St., Richmond, VA 23235 Paul.w.smith@email.com 804-555-6789 Mary Smith Mom Mary.smith4@email.com 804-555-1234 DBHDS SDMA Draft Sample Page 11 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 3 of 24 _N_ Help me decide where, when, and what to eat. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me make choices about drinking alcohol and using drugs. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people what I want and what I don’t want regarding my health and personal care. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people how I make choices about my health and personal care. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Make sure people understand what I am saying about my health and personal care. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ To help with my health and personal care these supporters may also do these things: (Examples: Attend medical appointments with me, talk directly to my doctors, help others understand what helps me calm down when I’m upset) These supporters MAY NOT do these things to help me with my health and personal care: (Examples: May not talk directly to doctors, may not attend medical appointments)

Help me look for new doctors, when needed.- All Supporters None.

DBHDS SDMA Draft Sample Page 12 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 4 of 23

Friends and Partners I DO _X_ / DO NOT ___ want help with decisions about my friends and partners. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number April Smith Sister 345 Main St., Richmond, VA 23235 asmith@coll.edu 804-555-1000 Rachael Jones ABA Therapist 45 Duncan Rd, Richmond, VA 23113 rjonesaba@email.com 703-777-6565 Adam Young Friend 56 W. Main St., Richmond, VA 23234 Ayoung56@email.com 804-888-9900 *To add a new row, place cursor in bottom right box and press Tab.

These supporters may do these things: Write Y for “yes” or N for “no” to say if your Supporters can or cannot help with each option. _N_ Help me understand and choose if I want to date and who I want to date. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand and make choices about birth control and pregnancy, and access medical care, if needed. ___ All Supporters/ _X_ Only Supporters Listed Here: _Adam Young, Rachael Jones___________ _N_ Help me make choices about sex. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me make choices about marriage. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me choose who to spend time with. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me tell people what I want and what I don’t want regarding my friends and partners. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people how I make choices about my friends and partners. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Make sure people understand what I am saying about my choices and decisions regarding my friends and partners. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ DBHDS SDMA Draft Sample Page 13 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 5 of 23 To help me with my friends and partners these supporters may also do these things: (Examples: Help me find groups/places where I could meet new friends/partners, talk directly to my friends and partners) None.

These supporters MAY NOT do these things to help me with my friends and partners: (Examples: May not talk directly to my friends and partners, may not decide who my friends and partners are, may not contact my friends and partners without my consent) None.

DBHDS SDMA Draft Sample Page 14 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 6 of 23

Money I DO _X_ / DO NOT ___ want help with decisions about money. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number Paul Smith Dad 345 Main St., Richmond, VA 23235 Paul.w.smith@email.com 804-555-6789 Mary Smith Mom 345 Main St., Richmond, VA 23235 Mary.smith4@email.com 804-555-1234 Rachael Jones ABA Therapist 45 Duncan Rd, Richmond, VA 23113 rjonesaba@email.com 703-777-6565 *To add a new row, place cursor in bottom right box and press Tab.

These supporters can help me in these ways: Write Y for “yes” or N for “no” to say if your Supporters can or cannot help with each option. _Y_ Get and look at my financial information, including bank records. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me get information about my finances. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me make big decisions about money (for example, opening a bank account, signing a lease). ___ All Supporters/ _X_ Only Supporters Listed Here: _Paul Smith, Mary Smith_______________ _Y_ Help me fill out financial forms and documents. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me keep a budget so I know how much money I can spend. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me pay rent and bills on time. ___ All Supporters/ _X_ Only Supporters Listed Here: _Paul Smith, Mary Smith_______________ _Y_ Help me make sure no one is taking my money or using it for themselves. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people what I want and what I don’t want regarding my money. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people how I make choices about my money. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Make sure people understand what I am saying about my choices and decisions regarding my money. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ DBHDS SDMA Draft Sample Page 15 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 7 of 23 To help me with my money these supports may also do these things: (Examples: Help me save money, Help me budget for larger purchase, look at and help me understand my Social Security benefits, help me apply for other benefits) None.

These supporters MAY NOT do these things to help me with my money: (Examples: May not tell me how to spend my money, may not spend my money without my consent, may not see my finances without my consent) None.

DBHDS SDMA Draft Sample Page 16 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 8 of 23

Where I Live and Community Living I DO _X_ / DO NOT ___ want help with decisions about where I live and how I live in my community. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number Paul Smith Dad 345 Main St., Richmond, VA 23235 Paul.w.smith@email.com 804-555-6789 Mary Smith Mom 345 Main St., Richmond, VA 23235 Mary.smith4@email.com 804-555-1234 Rachael Jones ABA Therapist 45 Duncan Rd, Richmond, VA 23113 rjonesaba@email.com 703-777-6565 *To add a new row, place cursor in bottom right box and press Tab.

These supporters can help me in these ways: Write Y for “yes” or N for “no” to say if your Supporters can or cannot help with each option. _N_ Get and look at information about places where I have lived. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me decide where to live. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me decide who to live with. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand chores, remind me to do chores, and help me do chores. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand any leases I am thinking about, and help me understand any rules of my home and community. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me make safe choices around the house (for example, turning off the stove, practicing for fire alarms). _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me make decisions about what to do and where to go in my free time. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me make decisions about transportation, and help me use transportation. _X_ All Supporters/ ___ Only Supporters Listed Here: __________________________________ _Y_ Help me with understanding, finding, hiring, and firing support staff and services. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me make decisions about traveling to places I go often (for example, getting to stores, work, friends’ homes). ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ DBHDS SDMA Draft Sample Page 17 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 9 of 23 _Y_ Help me make decisions about traveling to places I do not go often (for example, special events, vacations). _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people what I want and what I don’t want regarding where I live and what I do in my community. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people how I make choices about where I live and what I do in my community. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Make sure people understand what I am saying about my choices and decisions regarding where I live and what I do in my community. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ To help me with where I live and my community these supporters may also do these things: (Examples: Help me explore other ways to spend my days, talk directly to my paid supports, talk directly to my roommates)

Help me with issues with my roommates. – Only Supporters Listed Here: Rachael Jones These supporters MAY NOT do these things to help me with where I live and my community: (Examples: May not change where I live without my consent, may not decide how I spend my days, may not speak with my paid supports without my consent)

Talk to my roommates without me. – All Supporters DBHDS SDMA Draft Sample Page 18 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 10 of 23

School and Education I DO _X_ / DO NOT ___ want help with decisions about school and education. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number Mary Smith Mom 345 Main St., Richmond, VA 23235 Mary.smith4@email.com 804-555-1234 Paul Smith Dad 345 Main St., Richmond, VA 23235 Paul.w.smith@email.com 804-555-6789 *To add a new row, place cursor in bottom right box and press Tab.

These supporters can help me in these ways: Write Y for “yes” or N for “no” to say if your Supporters can or cannot help with each option. _Y_ Get and look at my education information, including seeing my education records under the Family Educational Rights and Privacy Act of 1974 (FERPA). A release is signed and attached to this agreement. _____ All Supporters/ _X_ Only Supporters Listed Here: _Mary Smith _______________________ _Y_ Help me make decisions about whether to go to school, and where to go. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me make decisions about special education and accommodations. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Attend education meetings with me, including IEP meetings and school conferences. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me make decisions about school activities and events. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people what I want and what I don’t want regarding my education. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people how I make choices about my education. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Make sure people understand what I am saying my education. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ DBHDS SDMA Draft Sample Page 19 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 11 of 23 To help me with my school and education these supporters may also do these things: (Examples: Help me understand my prevocational options, help me communicate my decisions about my prevocational interests to my teachers and school supports) None.

These supporters MAY NOT do these things to help me with my school and education: (Examples: May not attend school/IEP meetings, may not decide what supports I receive at school, may not see my grades or school reports) None.

DBHDS SDMA Draft Sample Page 20 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 12 of 23

Working I DO _X_ / DO NOT ___ want help with decisions about working. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number Paul Smith Dad 345 Main St., Richmond, VA 23235 Paul.w.smith@email.com 804-555-6789 Mary Smith Mom 345 Main St., Richmond, VA 23235 Mary.smith4@email.com 804-555-1234 Johnny Prime Theater Coach 676 Allen St., Richmond, VA 23234 theaterlv@email.com 804-888-3434 *To add a new row, place cursor in bottom right box and press Tab.

These supporters can help me in these ways: Write Y for “yes” or N for “no” to say if your Supporters can or cannot help with each option. _N_ Help me choose if I want to work. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand my work choices and apply for jobs. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand how working will affect my benefits (Social Security, Medicaid, etc.). _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand the benefits I can have at work (vacation time, sick leave, time off, etc.). _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me request benefits at work (vacation time, sick leave, time off, etc.). ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me make decisions about transitional services (services as I transition out of high school). ____ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me explore and make decisions about internships, apprenticeships, and/or mentoring. ___ All Supporters/ _X_ Only Supporters Listed Here: __Johnny Prime_______________________ _Y_ Help me make decisions about whether I need to take more classes or training to get a job I want, and help taking these classes. ___ All Supporters/ _X_ Only Supporters Listed Here: __Johnny Prime_______________________ _Y_ Help me make decisions about supported employment or other supports and services I need in order to work. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Attend meetings about my employment with my employment supporters, including Vocational Rehabilitation or other employment agencies. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ Page 21 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 13 of 23 _N_ Help me with career preparation and placement. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me request accommodations for my work. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me get to and from work every day. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me talk to my employer. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people what I want and what I don’t want regarding my work and work related supports. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people how I make choices about my work and work related supports. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Make sure people understand what I am saying about my work and work related supports. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ To help me with my work these supporters may also do these things: (Examples: Talk to my employment supports, help me understand and decide my work schedule, talk to my employer or supervisor) None.

These supporters MAY NOT do these things to help me with my work: (Examples: May not talk to my supervisor or employer without my consent, may not visit me at work, may not talk with my employment supports without my consent, may not dictate my work schedule) None.

Page 22 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith________________ Page 14 of 24

1. My Rights and Safety I DO _X_ / DO NOT ___ want help with decisions about my rights and safety. Here is a list of people I want to help me: These supporters can help me in these ways: Write Y for “yes” or N for “no” to say if your Supporters can or cannot help with each option. ___ Help me understand my rights as a voter and register to vote. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand my choices when voting at elections. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me cast my ballot when voting. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand and sign contracts and formal agreements. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand and get help if I am being treated badly (abuse, neglect, exploitation, undue influence, manipulation). _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me communicate to others and make sure people understand what I am communicating in regards to my rights and issues of safety (what I want and do not want when I’m upset or in crisis, what to do when interacting with emergency services). _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ DBHDS SDMA Draft Sample Page 23 of 47 First and Last Name Relationship Home Address Email Phone Number Paul Smith Dad 345 Main St., Richmond, VA 23235 Paul.w.smith@email.com 804-555-6789 Mary Smith Mom 345 Main St., Richmond, VA 23235 Mary.smith4@email.com 804-555-1234 Rachael Jones ABA Therapist 45 Duncan Rd, Richmond, VA 23113 rjonesaba@email.com 703-777-6565 *To add a new row, place cursor in bottom right box and press Tab.

N Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 15 of 23 To help me with my rights and safety these supporters may also do these things: (Examples: Help me understand benefits that I am eligible for, help me apply for additional benefits, may help me find and obtain legal services, may help me access help when I feel unsafe)

Help me understand benefits that I’m eligible for. – All Supporters

Help me apply for additional benefits. – All Supporters

Help me access help when I feel unsafe. – All Supporters These supporters MAY NOT do these things to help me with my rights and safety: (Examples: May not dictate who I can and cannot talk to, may not decide who I vote for, may not sign contracts for me)

1. May not sign contracts for me. – All Supporters DBHDS SDMA Draft Sample Page 24 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 16 of 23

Meeting and Talking with My Supporters I DO _X_ / DO NOT ___ want help coordinating meetings and talking with my Supporters. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number Paul Smith Dad 345 Main St., Richmond, VA 23235 Paul.w.smith@email.com 804-555-6789 *To add a new row, place cursor in bottom right box and press Tab.

These supporters can help me in these ways: Write Y for “yes” or N for “no” to say if your Supporters can or cannot help with each option. _Y_ Help me contact my Supporters to set up meetings. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me talk with my Supporters when I am upset or have a problem with them. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me keep my Supporters updated on how I am doing. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me keep my Supporters updated on what I am doing. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me communicate to my Supporters to make sure they understand what I am saying. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ To help me meet and talk with my Supports these supporters may also do these things: (Examples: Help me understand what my Supporters are telling me, help me communicate with my Supporters over email, text message, or the phone, Help advocate for me when meeting with my Supporters, Meet with my Supporters without me) None.

DBHDS SDMA Draft Sample Page 25 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 17 of 23 These supporters MAY NOT do these things to help me meet and talk with my Supporters: (Examples: May not meet with my Supporters without me, May not talk with my Supporters about me without me present) None.

DBHDS SDMA Draft Sample Page 26 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 18 of 23

Other I DO ___ / DO NOT _X_ want help with other decisions. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number *To add a new row, place cursor in bottom right box and press Tab.

These supporters may also help me in these other ways: Other: ___________________________________________________________________________ ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ Other: ___________________________________________________________________________ ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ Other: ___________________________________________________________________________ _____ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ Other: ___________________________________________________________________________ ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ These supporters MAY NOT do these other things to help me: DBHDS SDMA Draft Sample Page 27 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 19 of 23 Cancellation of Supported Decision-Making Agreement I, ____________________________________, am the creator of this agreement, which is all about me, and that makes me the Decision Maker. As the Decision Maker, I no longer want this Support Decision-Making Agreement. This agreement will no longer be effective as of the date indicated below. ______________________________________ _____________________ Signature of Decision Maker in This Agreement Date of Revocation Agreements By my signature below I, the Decision Maker, agree to consult and work with my Supporters in making decisions and in other matters that I need and to consider (think about) their guidance. This agreement starts when I sign it, and ends when I choose to end it. Any Supporter may leave the agreement by telling me in writing. If a Supporter leaves the agreement, the rest of the agreement continues.

By my signature below I, the Supporter, agree to be available as often as needed to give the Decision Maker my best advice and assistance. I agree to support the Decision Maker with honesty, good faith, and in their and only their stated best interest, in line with the Decision Maker’s values, needs, and preferences in order to assist them with making decisions relating to their life. When requested by the Decision Maker, I agree to help them plan and arrange for supports and services that will help them live safely and successfully in the community without a legal guardian. As the Supporter, I acknowledge that I might know private information about the Decision Maker and will respect their confidentiality. I agree not to use my position to abuse, exploit, manipulate, slander or exercise undue influence on the Decision Maker. If I am also a paid provider, I will not provide support in areas that would appear as a conflict of interest.

None of the parties to this agreement are required to sign it, and any of us can resign from it with 10 days written notice to the others. ______________________________________ __Sam Smith_____________________________ Signature of Decision Maker in This Agreement Printed Name of Decision Maker in This Agreement Date Signed: _05/01/2022_____ I agree to be a Supporter under this agreement: ______________________________________ _Paul Smith______________________________ Signature of Supporter 1 Printed Name of Supporter 1 Date Signed: _05/01/2022_____ ________________________________________ _Mary Smith______________________________ Signature of Supporter 2

Printed Name of Supporter 2 Date Signed: _05/01/2022_____ ________________________________________ _April Smith______________________________ Signature of Supporter 3

Printed Name of Supporter 3 Date Signed: _05/01/2022_____ This page can be printed again if space for more Supporter’s signatures is needed.

DBHDS SDMA Draft Sample Page 28 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 19 of 23 Cancellation of Supported Decision-Making Agreement I, ____________________________________, am the creator of this agreement, which is all about me, and that makes me the Decision Maker. As the Decision Maker, I no longer want this Support Decision-Making Agreement. This agreement will no longer be effective as of the date indicated below. ______________________________________ _____________________ Signature of Decision Maker in This Agreement Date of Revocation Agreements By my signature below I, the Decision Maker, agree to consult and work with my Supporters in making decisions and in other matters that I need and to consider (think about) their guidance. This agreement starts when I sign it, and ends when I choose to end it. Any Supporter may leave the agreement by telling me in writing. If a Supporter leaves the agreement, the rest of the agreement continues.

By my signature below I, the Supporter, agree to be available as often as needed to give the Decision Maker my best advice and assistance. I agree to support the Decision Maker with honesty, good faith, and in their and only their stated best interest, in line with the Decision Maker’s values, needs, and preferences in order to assist them with making decisions relating to their life. When requested by the Decision Maker, I agree to help them plan and arrange for supports and services that will help them live safely and successfully in the community without a legal guardian. As the Supporter, I acknowledge that I might know private information about the Decision Maker and will respect their confidentiality. I agree not to use my position to abuse, exploit, manipulate, slander or exercise undue influence on the Decision Maker. If I am also a paid provider, I will not provide support in areas that would appear as a conflict of interest.

None of the parties to this agreement are required to sign it, and any of us can resign from it with 10 days written notice to the others. ______________________________________ __Sam Smith_____________________________ Signature of Decision Maker in This Agreement Printed Name of Decision Maker in This Agreement Date Signed: _05/01/2022_____ I agree to be a Supporter under this agreement: ______________________________________ _Rachael Jones___________________________ Signature of Supporter 1 Printed Name of Supporter 1 Date Signed: _05/01/2022_____ ________________________________________ _Johnny Prime____________________________ Signature of Supporter 2

Printed Name of Supporter 2 Date Signed: _05/01/2022_____ ________________________________________ _Adam Young_____________________________ Signature of Supporter 3

Printed Name of Supporter 3 Date Signed: _05/01/2022_____ This page can be printed again if space for more Supporter’s signatures is needed.

DBHDS SDMA Draft Sample Page 29 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 20 of 23 Supported Decision-Making Facilitator (Optional): By my signature below I, the Facilitator, agree to assist the Decision Maker with coordinating meetings with their Supporters, if and when needed. I agree to make reasonable efforts to ensure that the Supporters under this agreement are acting honestly, in good faith, and in accordance with the choices of the Decision Maker. If I suspect abuse, exploitation, manipulation, neglect, or undue influence on the Decision Maker by a Supporter I will discuss my concerns with both the Decision Maker and the Supporter, and follow the Protocols for Addressing Abuse and Exploitation. I also agree to help and advise the Decision Maker, should they have issues or concerns with any of their Supporters. If I am also a Supporter, I will take necessary steps to prevent any potential conflict with my role as the Facilitator.

None of the parties to this agreement are required to sign it, and any of us can resign from it with 10 days written notice to the others. ______________________________________ __Sam Smith_____________________________ Signature of Decision Maker in This Agreement Printed Name of Decision Maker in This Agreement Date Signed: _05/01/2022_____ ______________________________________ _Paul Smith______________________________ Signature of Facilitator Printed Name of Facilitator Date Signed: _05/01/2022_____ DBHDS SDMA Draft Sample Page 30 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 21 of 23 Notary (Optional):

COMMONWEALTH OF VIRGINIA COUNTY OF ______________________ On (date) __________________ (name of Decision Maker) _____________________________ appeared and verified their identity, acknowledged this Supported Decision- Making Agreement, and affixed their signature on the agreements page above.

NOTARY _________________________________________ Signature

REGISTRATION NUMBER __________________________

MY COMMISSION EXPIRES _________________________ SEAL DBHDS SDMA Draft Sample Page 31 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 22 of 23 Changes Changes to this Supported Decision-Making Agreement can be made at any time by the Decision Maker to add a new Supporter(s) and/or adjust how Supporters provide support. Use the chart below to track changes to the Supported Decision-Making Agreement. Print this page again if space for more Amendments is needed or fill out a new Supported Decision-Making Agreement.

Change 1: Date:__________________ Change: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________ Signature of Decision Maker ________________________________________ ________________________________________ Signature of Supporter(s) Involved Signature of Supporter(s) Involved Change 2: Date:__________________ Change: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________ Signature of Decision Maker ________________________________________ ________________________________________ Signature of Supporter(s) Involved Signature of Supporter(s) Involved Change 3: Date:__________________ Change: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________ Signature of Decision Maker ________________________________________ ________________________________________ Signature of Supporter(s) Involved Signature of Supporter(s) Involved Page 32 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith________________ Page 23 of 23 Cancellations The Decision Maker and/or Supporters may cancel their agreement at any time. This cancellation will not affect any decisions made or action taken on the basis of the initial Supported Decision-Making Agreement prior to receiving this notice.

Cancelled Supporter(s) 1: Date:__________________ Name of Cancelled Supporter(s): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _______________________________________ Signature of Decision Maker Cancelled Supporter(s) 2: Date:__________________ Name of Cancelled Supporter(s): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ ________________________________________ Signature of Decision Maker Cancelled Supporter(s) 3: Date:__________________ Name of Cancelled Supporter(s): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ ________________________________________ Signature of Decision Maker Page 33 of 47 DBHDS SDMA Draft Sample DBHDS SDMA Draft Sample Discovery Tools These three (3) tools can be used to gather helpful information when creating a Supported Decision-Making Agreement. These include 1) When Do I Want Support? tool, 2) What Kind of Support Do I Want? tool, and 3) Relationship Map tool.

Page 34 of 47 Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 1 of 10 When do I want support? Everyone needs support with making some decisions, not just people with disabilities. Some people ask for help from a doctor when they are sick or before taking medicine. Some people ask a mechanic before buying a new car, or ask a friend before moving into a new apartment. When you get help from others with making decisions this is called Supported Decision-Making.

You can use this form to help you fill out the Commonwealth of Virginia’s Supported Decision-Making Agreement. Place a check () in box next to each sentence to say if you can do this on your own, if you can do it with support, or if you need someone else to do the task for you. You do not have to place a check in each area.

If you check “I can do this with support” think about who you might ask to support you, as well as what kind of support you want or need. You can also use the attached Relationship Map and/or What Kind of Support Do I Want? tools to help answer these questions.

I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Health and Personal Care Get my health care information.  Choose when to go to the doctor.  Make and keep my doctor and dentist appointments.  Understand and make medical choices in serious situations (for example, surgery, big injuries).  Understand and make medical choices in an emergency.  Page 35 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 2 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Health and Personal Care- continued Understand and make medical choices in everyday situations (for example, check-up, getting medicine from the drug store).  Understand my medications, help remind me about my medications, and assist me in getting and taking my medications.  Understand personal hygiene, help remind me about my personal hygiene, and help me with my personal hygiene.  Choose what to wear and help me get dressed, if needed.  Decide where, when, and what to eat.  Make choices about drinking alcohol and using drugs.  Tell people what I want and what I don’t want regarding my health and personal care.  Tell people how I make choices about my health and personal care.  Make sure people understand what I am saying about my health and personal care.  Page 36 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 3 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Friends and Partners Understand and choose if I want to date and who I want to date.  Understand and make choices about birth control and pregnancy, and access medical care, if needed.  Make choices about sex.  Make choices about marriage.  Choose who to spend time with.  Tell people what I want and what I don’t want regarding my friends and partners.  Tell people how I make choices about my friends and partners.  Make sure people understand what I am saying about my choices and decisions regarding my friends and partners.  Page 37 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 4 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Money Get information about my finances.  Make big decisions about money (for example, opening a bank account, signing a lease).  Fill out financial forms and documents.  Keep a budget so I know how much money I can spend.  Pay rent and bills on time.  Make sure no one is taking my money or using it for themselves.  Tell people what I want and what I don’t want regarding my money.  Make sure people understand what I am saying about my choices and decisions regarding my money.  Page 38 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 5 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Where I Live and Community Living Get and look at information about places where I have lived.  Decide where to live.  Decide who to live with.  Understand chores, remind me to do chores, and help me do chores.  Understand any leases I am thinking about, and help me understand any rules of my home and community.  Make safe choices around the house (for example, turning off the stove, practicing for fire alarms).  Make decisions about what to do and where to go in my free time.  Make decisions about transportation, and help me use transportation.  Understand, find, hire, and fire support staff and services.  Make decisions about traveling to places I go often (for example, getting to stores, work, friends’ homes).  Page 39 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 6 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Where I Live and Community Living- continued Make decisions about traveling to places I do not go often (for example, special events, vacations).  Tell people what I want and what I don’t want regarding where I live and what I do in my community.  Tell people how I make choices about where I live and what I do in my community.  Make sure people understand what I am saying about my choices and decisions regarding where I live and what I do in my community.  School and Education Get and look at my education information and records.  Make decisions about whether to go to school, and where to go.  Make decisions about special education and accommodations.  Attend education meetings, including IEP meetings and school conferences.  Make decisions about school activities and events.  Page 40 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 7 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

School and Education- continued Tell people what I want and what I don’t want regarding my education.  Tell people how I make choices about my education.  Make sure people understand what I am saying my education.  Working Choose if I want to work.  Understand my work choices and apply for jobs.  Understand how working will affect my benefits (Social Security, Medicaid, etc.).  Understand the benefits I can have at work (vacation time, sick leave, time off, etc.).  Request benefits at work (vacation time, sick leave, time off, etc.).  Make decisions about transitional services (services as I transition out of high school).  Page 41 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 8 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Working- continued Explore and make decisions about internships, apprenticeships, and/or mentoring.  Make decisions about whether I need to take more classes or training to get a job I want, and help taking these classes.  Make decisions about supported employment or other supports and services I need in order to work.  Attend meetings with my employment supporters, including Vocational Rehabilitation or other employment agencies.  Make decisions about career preparation and placement.  Request accommodations for my work.  Get to and from work every day.  Talk to my employer.  Tell people what I want and what I don’t want regarding my work and work related supports.  Tell people how I make choices about my work and work related supports.  Page 42 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 9 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Working- continued Make sure people understand what I am saying about my work and work related supports.  My Rights and Safety Understand my rights as a voter and register to vote.  Understand my choices when voting at elections.  Cast my ballot when voting.  Understand and sign contracts and formal agreements.  Understand and get help if I am being treated badly (abuse, neglect, exploitation, undue influence, manipulation).  Communicate to others and make sure people understand what I am saying in regards to my rights and issues of safety.  Meeting and Talking with My Supporters Contact my Supporters to set up meetings.  Talk with my Supporters when I am upset or have a problem with them.  Page 43 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 10 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Meeting and Talking with My Supporters- continued Keep my Supporters updated on how I am doing.  Keep my Supporters updated on what I am doing.  Communicate to my Supporters to make sure they understand what I am saying.  Other Choices or Activities Page 44 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from How to Make a Supported Decision-Making Agreement, A Guide for People with Disabilities and their Families, developed by the American Civil Liberties Union (ACLU).

Page 1 of 2 What kind of support do I want? Support (help) can look different for everyone and can be different for each choice or activity.

You can use this form to help you think about the different ways people can help and how you might want your Supporters to help you. Place a check () in the box next to each type of help you think you might want or need.  Have help filling out/writing on forms, such as my Supported Decision-Making Agreement.

Have information written and/or spoken in simple words (plain-language).

Have information provided in pictures.  Talk to your Supporters to know what your choices are.  Research to learn more about your choices on your own or with help from your Supporters.  Talk to experts (people who know a lot about your choices) about your options and choices.  Talk to your Supporters to get advice.

Page 45 of 47 Types of Support DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from How to Make a Supported Decision-Making Agreement, A Guide for People with Disabilities and their Families, developed by the American Civil Liberties Union (ACLU).

Page 2 of 2 Types of Support Take extra time to think about your choices.  Get help making a pros and cons list (a list of good and bad sides of each choice).  Have Supporters remind you about your values (what is most important to you) and how these might impact your choices.  Help trying out different choices to see how you feel and which choice you like.

Have help from your Supporters with communicating your choice to others.

Use technology (a phone or computer) to help communicate your choice to others.  Receive reminders about important dates and times.  Have a Supporter come to meetings and appointments with you.

Take classes (on-line or in person) to help learn more about choices.

Page 46 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool The Relationship Map is a Person Centered Thinking tool developed by The Learning Community for Person Centered Practiced.

Page 1 of 1 Who do I want to support me? Supported Decision-Making Agreements are made up of Supporters and Decision Makers. You are the Decision Maker and the people you choose to help you are the Supporters. You can choose anyone you want to be your Supporter and you can choose to have many supporters. Some Supporters might help you in one area of life and others might help you in several areas. The decision is up to you.

When thinking about who you want as a Supporter, think about people that you trust and talk to them to see if they will agree to be your Supporter.

You can use this form to help you think about the different people who already help you in your life.

Your name goes in the center circle. Write the names of the people who help you in the category that best fits them. People who you feel closest to will go in the circle closest to your name. People that you do not feel as close to or that you do not look to for help as often can go in the outer circle. ______Sam’s Relationship Map Family People who support me at work or school.

People who support me at home and other places.

Friends Sam April Dad Mom Uncle Bill Aunt Sue Grandma Grandpa Ms. Schwartz (teacher) Ms. Jones (vo. Tech) Mr. Dunn (counselor) Adam Cara Paul Melanie Mike Kim David Mark Sarah Rachael (ABA therapist) Johnny (Theater Coach) Dr. Taylor (PCP) DBHDS SDMA Draft Sample Page 47 of 47

DBHDS SDMA Draft Sample Page 1 of 47 DBHDS Office of Provider Development Supported Decision-Making Agreement Draft Sample Effective: July 15, 2022 Purpose: This draft sample of Virginia’s Supported Decision-Making Agreement (SDMA) is mandated by § 37.2-314.3 of the Virginia Code via House Bill 2230, with instructions included. SDMAs document support preferences, methods, and supporters, while the decision maker retains final authority.

SDMAs are non-binding, less restrictive alternatives to guardianship. Virginia § 37.2-314.3 calls participants “principals,” but here, “decision maker.” Supporters are those identified for support. Data and recommendations will be reported to the General Assembly by November 1, 2022.

Regulations addressed: The Code of Virginia § 37.2-314.3 defines supported decision-making agreements as “an agreement between a principal and a supporter that sets out the specific terms of support to be provided by the supporter, including (i) helping the principal monitor and manage his medical, financial, and other affairs; (ii) assisting the principal in accessing, obtaining, and understanding information relevant to decisions regarding his affairs; (iii) assisting the principal in understanding information, options, responsibilities, and consequences of decisions; and (iv) ascertaining the wishes and decisions of the principal regarding his affairs, assisting in communicating such wishes and decisions to other persons, and advocating to ensure the wishes and decisions of the principal are implemented.” The use of supported decision-making and supported decision-making agreements in Virginia aligns with Human Rights Regulations regarding Participation in Decision Making and Consent [12VAC35-115-70] as “each individual has a right to participate meaningfully in decisions regarding all aspects of services affecting him.” SDMAs help ensure that the decision maker actively participates in decisions involving all aspects of their life and is supported in exercising their legal, civil, and human rights.

Guidance Document DD 06 DBHDS SDMA Draft Sample Page 2 of 47 Instructions for completing Virginia’s Supported Decision-Making Agreement template.

Commonwealth of Virginia: Supported Decision-Making Agreement Page 1 of 6 Step 1: Decide if a supported decision-making agreement is right for you.

A supported decision-making agreement is suitable if you can make decisions independently or with trusted help. You must be 18+ and legally capable. If you have a court-appointed guardian or conservator, you may lack legal decision-making rights. This agreement is not a court-ordered legal document, but your choices should be respected, and you retain final decision-making authority.

Step 2: Decide when you want support.

You may want support in some areas but not others.

Use the When Do I Want Support? tool to consider if you: can do it alone, with help, or need someone else to do it.

Choices on this tool match those on the Virginia Supported Decision-Making Agreement, in the same order.

Step 3: Decide what support you want.

Support varies per person and activity. Use the What Kind of Support Do I Want? tool to identify and document your support preferences.

Step 4: Choose your supporters.

The agreement includes supporters and the decision maker. You choose supporters, possibly many, who may assist with one or multiple areas. The choice is yours.

DBHDS SDMA Draft Sample Page 3 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Page 2 of 6 You may select a supporter and facilitator to ensure the agreement functions, but having one is optional.

Choose trusted individuals who understand your preferences. Use the Relationship Map tool to identify potential supporters.

Step 5: Fill out your supported decision-making agreement.

Meet with your supporters to discuss support needs and preferences, using the tools as needed.

Review and complete the agreement with supporters, asking questions if needed. You may do it yourself or with trusted help.

On page 1, enter your name as decision maker, contact info, and the agreement’s start date. Also list other supports like Power of Attorney, Medical Directive, or Financial Fiduciary.

Fiduciaries include Social Security Payees, VA Fiduciaries, Trusts, or Power of Attorney designees.

Forms include HIPAA (health info), Educational Release (school info), and others like Educational Power of Attorney or additional documents listing support persons.

Check () if you have other supports, regardless of attaching copies.

Pages 2-18 list nine (9) life areas where you might make choices. These include:

1. Health and Personal Care,
2. Friends and Partners,
3. Money,
4. Where I Live and Community Living,
5. School and Education,
6. Working,
7. My Rights and Safety,
8. Meeting and Talking with My Supporters, and
9. Other - The life area of Other allows writing in additional choices or activities for help or not listed elsewhere.

For each area, check if you want help. If not, skip further questions for that area.

If support is desired, list supporters’ contact info and mark “Y” or “N” next to each support statement, matching the support tool order.

For each “Y” answer, check if all supporters or some help. List specific supporters next to “Only Supporters Listed Here” if not all.

In each area, add extra support needs or restrictions not listed.

Page 19 is the signing page where you and supporters agree. Read and understand before signing. For more than three supporters, print additional pages.

Leave the grey box at the bottom blank initially; complete it only if you want to cancel the agreement later.

Page 20 allows you to select a facilitator to assist with managing the agreement and coordinating supporters. Having one is optional.

Page 21 offers the option for a notary to sign and stamp your Supported Decision-Making Agreement; it is optional. Notaries are available at banks and courts.

You can update your Supported Decision-Making Agreement on page 22 by noting the date, change, and signing. Supporters added must also sign. You can do this up to three times.

You may decide to stop support from someone at any time.

To stop support, complete page 23 by noting the date, supporter’s name, and signing. You can do this up to three times.

After completing your Supported Decision-Making Agreement, follow the next steps as outlined.

After completing your agreement, give copies to supporters, doctors, case managers, and others involved. Keep a copy for yourself. Supporters cannot be taken to court over advice or support; you retain decision-making rights and can change supporters anytime.

Example: Sam, 18, with autism, communicates verbally, in high school, learning job skills, considering graduation to pursue acting.

Sam lives with his parents and sister, who visits from college.

Sam plans to live alone in the city after graduation, but parents worry he may be exploited. He has never budgeted or paid bills and trusts everyone he meets.

Sam and family use a supported decision-making agreement to assist with decisions, supporting his independence and understanding his right to take risks and learn from them.

Nikkia, 25, works part-time at Target assisting customers and rehanging clothes. She has cerebral palsy and an intellectual disability.

Nikkia has lived independently for 3 years in an accessible apartment. She trusts friends, neighbors, and coworkers who help her. Family is distant.

DBHDS SDMA Draft Sample Page 7 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Page 6 of 6 Nikkia talks, but strangers may not understand her. She prefers not to use communication technology like tablets.

After a fall and hospital visit where doctors couldn't understand her, Nikkia decided to list her support persons in an advanced directive and other documents.

Nikkia made a supported decision-making agreement with her Supporters and shared copies with her doctors, landlord, employer, and case manager to clarify her support preferences.

Maria, 35, lives with her mother and has an intellectual disability.

As a toddler, she had seizures causing an acquired brain injury.

Maria does not speak but uses sign language, pictures, and a tablet program.

Maria attends a day program and volunteers at the SPCA. Her mother helps with medications, cooking, and cleaning daily.

Her mother assists with hygiene, dressing, and transportation, including scheduling rides when needed.

As her mother ages, family worries about support. Her mother never sought guardianship, but acted as Payee, Power of Attorney, and Authorized Rep, preserving Maria’s rights. She does not want guardianship.

Maria and family chose a supported decision-making agreement to support her independence. Her mother feels relieved knowing it’s in place.

This section relates to Sam’s story on page 5 of the instructions.

Page 9: This agreement should be communicated accessibly. A facilitator may oversee it; a notary is optional.

I, Sam Smith, created this agreement about me, making me the Decision Maker. I chose trusted Supporters.

My Supporters are those who agree to help me understand and make choices.

Supporters do not decide for me; they provide information, advice, and support for my decision-making.

I can change this agreement anytime by editing or adding, initialing, and signing the Changes and Cancellation pages.

To end the agreement, complete the Cancellation section on the attached page.

Decision Maker: Sam Smith; Contact: cell 804-555-8000; Effective date: 05/01/2022. Support forms attached/not attached: Power of Attorney, Medical Directive, Fiduciary, HIPAA, Education, others as specified. DBHDS SDMA Draft Sample Page 10 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for:___Sam Smith___________ Page 2 of 24

1. Health and Personal Care I DO _X_ / DO NOT ___ want help with health and personal care decisions. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number *To add a new row, place cursor in bottom right box and press Tab.

These supporters may do these things: Write Y/N for help with options. _Y_ Can access my health info with signed release. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me choose when to see the doctor. ____ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me schedule and keep appointments. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand and make medical decisions in serious situations. _X__ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand and make emergency medical decisions. _X__ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand and make decisions in everyday situations. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand, remind, and assist with medications. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help with personal hygiene and reminders. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me choose and get dressed. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me decide where, when, and what to eat. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me make choices about drinking alcohol and using drugs. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people what I want and what I don’t want regarding my health and personal care. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people how I make choices about my health and personal care. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Make sure people understand what I am saying about my health and personal care. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ To help with my health and personal care these supporters may also do these things: (Examples: Attend medical appointments with me, talk directly to my doctors, help others understand what helps me calm down when I’m upset) These supporters MAY NOT do these things to help me with my health and personal care: (Examples: May not talk directly to doctors, may not attend medical appointments)

Help me find new doctors when needed.

DBHDS SDMA Draft Sample Page 12 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 4 of 23

Friends and Partners I DO _X_ / DO NOT ___ want help with decisions about my friends and partners. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number April Smith Sister 345 Main St., Richmond, VA 23235 asmith@coll.edu 804-555-1000 Rachael Jones ABA Therapist 45 Duncan Rd, Richmond, VA 23113 rjonesaba@email.com 703-777-6565 Adam Young Friend 56 W. Main St., Richmond, VA 23234 Ayoung56@email.com 804-888-9900 *To add a new row, place cursor in bottom right box and press Tab.

Supporters may help with: Decide if I want to date, choose birth control, make decisions about sex and marriage, select friends/partners, and communicate my preferences. Supporters may NOT decide or contact my friends/partners without my consent. DBHDS SDMA Draft Sample Page 13 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 5 of 23 Supporters may help me find groups or meet new friends/partners; support direct communication. None listed.

Supporters may NOT contact or decide my friends/partners without my consent. None listed.

DBHDS SDMA Draft Sample Page 14 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 6 of 23

Money I DO _X_ / DO NOT ___ want help with decisions about money. Here is a list of people I want to help me: Supporters: Name, Relationship, Address, Email, Phone. Example: Paul Smith (Dad), 345 Main St., Richmond, VA, 804-555-6789; Mary Smith (Mom), 345 Main St., Richmond, VA, 804-555-1234; Rachael Jones (Therapist), 45 Duncan Rd, Richmond, VA, 703-777-6565. To add, press Tab.

Supporters may help with: Accessing financial info, making decisions, filling forms, budgeting, paying bills, and ensuring no misuse. Supporters may NOT decide or communicate about my money without consent. DBHDS SDMA Draft Sample Page 15 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 7 of 23 Supporters may help me save, budget, understand benefits, or apply for benefits. None listed.

Supporters may NOT decide or access my finances without my consent. None listed.

DBHDS SDMA Draft Sample Page 16 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 8 of 23

Where I Live and Community Living I DO _X_ / DO NOT ___ want help with decisions about where I live and how I live in my community. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number Paul Smith Dad 345 Main St., Richmond, VA 23235 Paul.w.smith@email.com 804-555-6789 Mary Smith Mom 345 Main St., Richmond, VA 23235 Mary.smith4@email.com 804-555-1234 Rachael Jones ABA Therapist 45 Duncan Rd, Richmond, VA 23113 rjonesaba@email.com 703-777-6565 *To add a new row, place cursor in bottom right box and press Tab.

These supporters can help me in these ways: Write Y for “yes” or N for “no” to say if your Supporters can or cannot help with each option. _N_ Get and look at information about places where I have lived. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me decide where to live. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me decide who to live with. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand chores, remind me to do chores, and help me do chores. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand any leases I am thinking about, and help me understand any rules of my home and community. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me make safe choices around the house (for example, turning off the stove, practicing for fire alarms). _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me make decisions about what to do and where to go in my free time. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me make decisions about transportation, and help me use transportation. _X_ All Supporters/ ___ Only Supporters Listed Here: __________________________________ _Y_ Help me with understanding, finding, hiring, and firing support staff and services. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me make decisions about traveling to places I go often (for example, getting to stores, work, friends’ homes). ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ DBHDS SDMA Draft Sample Page 17 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 9 of 23 _Y_ Help me make decisions about traveling to places I do not go often (for example, special events, vacations). _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people what I want and what I don’t want regarding where I live and what I do in my community. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people how I make choices about where I live and what I do in my community. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Make sure people understand what I am saying about my choices and decisions regarding where I live and what I do in my community. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ To help me with where I live and my community these supporters may also do these things: (Examples: Help me explore other ways to spend my days, talk directly to my paid supports, talk directly to my roommates)

Supporters, including Rachael Jones, may help with roommate issues but may NOT change residence or decide daily activities without my consent.

Talk to my roommates without me. – All Supporters DBHDS SDMA Draft Sample Page 18 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 10 of 23

School and Education I DO _X_ / DO NOT ___ want help with decisions about school and education. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number Mary Smith Mom 345 Main St., Richmond, VA 23235 Mary.smith4@email.com 804-555-1234 Paul Smith Dad 345 Main St., Richmond, VA 23235 Paul.w.smith@email.com 804-555-6789 *To add a new row, place cursor in bottom right box and press Tab.

These supporters can help me in these ways: Write Y for “yes” or N for “no” to say if your Supporters can or cannot help with each option. _Y_ Get and look at my education information, including seeing my education records under the Family Educational Rights and Privacy Act of 1974 (FERPA). A release is signed and attached to this agreement. _____ All Supporters/ _X_ Only Supporters Listed Here: _Mary Smith _______________________ _Y_ Help me make decisions about whether to go to school, and where to go. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me make decisions about special education and accommodations. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Attend education meetings with me, including IEP meetings and school conferences. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me make decisions about school activities and events. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people what I want and what I don’t want regarding my education. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people how I make choices about my education. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Make sure people understand what I am saying my education. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ DBHDS SDMA Draft Sample Page 19 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 11 of 23 To help me with my school and education these supporters may also do these things: (Examples: Help me understand my prevocational options, help me communicate my decisions about my prevocational interests to my teachers and school supports) None.

These supporters MAY NOT do these things to help me with my school and education: (Examples: May not attend school/IEP meetings, may not decide what supports I receive at school, may not see my grades or school reports) None.

DBHDS SDMA Draft Sample Page 20 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 12 of 23

Working I DO _X_ / DO NOT ___ want help with decisions about working. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number Paul Smith Dad 345 Main St., Richmond, VA 23235 Paul.w.smith@email.com 804-555-6789 Mary Smith Mom 345 Main St., Richmond, VA 23235 Mary.smith4@email.com 804-555-1234 Johnny Prime Theater Coach 676 Allen St., Richmond, VA 23234 theaterlv@email.com 804-888-3434 *To add a new row, place cursor in bottom right box and press Tab.

These supporters can help me in these ways: Write Y for “yes” or N for “no” to say if your Supporters can or cannot help with each option. _N_ Help me choose if I want to work. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand my work choices and apply for jobs. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand how working will affect my benefits (Social Security, Medicaid, etc.). _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand the benefits I can have at work (vacation time, sick leave, time off, etc.). _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me request benefits at work (vacation time, sick leave, time off, etc.). ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me make decisions about transitional services (services as I transition out of high school). ____ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me explore and make decisions about internships, apprenticeships, and/or mentoring. ___ All Supporters/ _X_ Only Supporters Listed Here: __Johnny Prime_______________________ _Y_ Help me make decisions about whether I need to take more classes or training to get a job I want, and help taking these classes. ___ All Supporters/ _X_ Only Supporters Listed Here: __Johnny Prime_______________________ _Y_ Help me make decisions about supported employment or other supports and services I need in order to work. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Attend meetings about my employment with my employment supporters, including Vocational Rehabilitation or other employment agencies. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ Page 21 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 13 of 23 _N_ Help me with career preparation and placement. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me request accommodations for my work. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me get to and from work every day. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me talk to my employer. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people what I want and what I don’t want regarding my work and work related supports. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me tell people how I make choices about my work and work related supports. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Make sure people understand what I am saying about my work and work related supports. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ To help me with my work these supporters may also do these things: (Examples: Talk to my employment supports, help me understand and decide my work schedule, talk to my employer or supervisor) None.

These supporters MAY NOT do these things to help me with my work: (Examples: May not talk to my supervisor or employer without my consent, may not visit me at work, may not talk with my employment supports without my consent, may not dictate my work schedule) None.

Page 22 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith________________ Page 14 of 24

1. My Rights and Safety I DO _X_ / DO NOT ___ want help with decisions about my rights and safety. Here is a list of people I want to help me: These supporters can help me in these ways: Write Y for “yes” or N for “no” to say if your Supporters can or cannot help with each option. ___ Help me understand my rights as a voter and register to vote. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand my choices when voting at elections. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me cast my ballot when voting. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand and sign contracts and formal agreements. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me understand and get help if I am being treated badly (abuse, neglect, exploitation, undue influence, manipulation). _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me communicate to others and make sure people understand what I am communicating in regards to my rights and issues of safety (what I want and do not want when I’m upset or in crisis, what to do when interacting with emergency services). _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ DBHDS SDMA Draft Sample Page 23 of 47 Supporters: Name, Relationship, Address, Email, Phone. Example: Paul Smith (Dad), 345 Main St., Richmond, VA, 804-555-6789; Mary Smith (Mom), 345 Main St., Richmond, VA, 804-555-1234; Rachael Jones (Therapist), 45 Duncan Rd, Richmond, VA, 703-777-6565. To add, press Tab.

N Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 15 of 23 To help me with my rights and safety these supporters may also do these things: (Examples: Help me understand benefits that I am eligible for, help me apply for additional benefits, may help me find and obtain legal services, may help me access help when I feel unsafe)

Help me understand benefits that I’m eligible for. – All Supporters

Help me apply for additional benefits. – All Supporters

Help me access help when I feel unsafe. – All Supporters These supporters MAY NOT do these things to help me with my rights and safety: (Examples: May not dictate who I can and cannot talk to, may not decide who I vote for, may not sign contracts for me)

1. Supporters cannot sign contracts for me. – Supported Decision-Making Agreement for: __Sam Smith__.

Meeting and Talking with My Supporters I DO _X_ / DO NOT ___ want help coordinating meetings and talking with my Supporters. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number Paul Smith Dad 345 Main St., Richmond, VA 23235 Paul.w.smith@email.com 804-555-6789 *To add a new row, place cursor in bottom right box and press Tab.

These supporters can help me in these ways: Write Y for “yes” or N for “no” to say if your Supporters can or cannot help with each option. _Y_ Help me contact my Supporters to set up meetings. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me talk with my Supporters when I am upset or have a problem with them. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me keep my Supporters updated on how I am doing. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _N_ Help me keep my Supporters updated on what I am doing. ___ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ _Y_ Help me communicate to my Supporters to make sure they understand what I am saying. _X_ All Supporters/ ___ Only Supporters Listed Here: ____________________________________ To help me meet and talk with my Supports these supporters may also do these things: (Examples: Help me understand what my Supporters are telling me, help me communicate with my Supporters over email, text message, or the phone, Help advocate for me when meeting with my Supporters, Meet with my Supporters without me) None.

DBHDS SDMA Draft Sample Page 25 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 17 of 23 These supporters MAY NOT do these things to help me meet and talk with my Supporters: (Examples: May not meet with my Supporters without me, May not talk with my Supporters about me without me present) None.

DBHDS SDMA Draft Sample Page 26 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 18 of 23

Other I DO ___ / DO NOT _X_ want help with other decisions. Here is a list of people I want to help me: First and Last Name Relationship Home Address Email Phone Number *To add a new row, place cursor in bottom right box and press Tab.

Supporters may help in other ways: list supporters and restrictions. This page may be printed again if needed. Cancellation of Supported Decision-Making Agreement I, the creator, am the Decision Maker. I can revoke this agreement by signing below. It starts when I sign and ends when I choose. Supporters may leave in writing; the rest continue.

Supporters agree to be available, support honestly, respect confidentiality, avoid abuse or undue influence, and not support in conflict areas if paid.

Parties may resign with 10 days' notice. Signatures: Decision Maker: Sam Smith, Date: 05/01/2022. Supporters: Paul Smith, Mary Smith, dates: 05/01/2022.

Supporter 2: April Smith, Date: 05/01/2022. Supporter 3 signature follows.

Supporter 3: Name, Date: 05/01/2022. Page printable for more signatures.

DBHDS SDMA Draft Sample Page 28 of 47 Commonwealth of Virginia: Supported Decision-Making Agreement Supported Decision-Making Agreement for: __Sam Smith_________________ Page 19 of 23 Cancellation of Supported Decision-Making Agreement Same as paragraph 8, revocation clause repeated.

By my signature below I, the Supporter, agree to be available as often as needed to give the Decision Maker my best advice and assistance. I agree to support the Decision Maker with honesty, good faith, and in their and only their stated best interest, in line with the Decision Maker’s values, needs, and preferences in order to assist them with making decisions relating to their life. When requested by the Decision Maker, I agree to help them plan and arrange for supports and services that will help them live safely and successfully in the community without a legal guardian. As the Supporter, I acknowledge that I might know private information about the Decision Maker and will respect their confidentiality. I agree not to use my position to abuse, exploit, manipulate, slander or exercise undue influence on the Decision Maker. If I am also a paid provider, I will not provide support in areas that would appear as a conflict of interest.

Parties may resign with 10 days' notice. Signatures: Sam Smith, Rachael Jones, Johnny Prime, dates: 05/01/2022.

Supporter 2: Adam Young, Date: 05/01/2022. Supporter 3 signature follows.

Printed Name of Supporter 3 Date Signed: _05/01/2022_____ This page can be printed again if space for more Supporter’s signatures is needed.

Facilitator agrees to assist, coordinate meetings, ensure honest support, address concerns, and avoid conflicts if also a Supporter.

Parties may resign with 10 days' notice. Signatures: Sam Smith, Facilitator: Paul Smith, date: 05/01/2022. Notary optional.

Virginia County: on (date), Decision Maker (name) appeared, verified ID, acknowledged and signed above.

NOTARY _________________________________________ Signature

REGISTRATION NUMBER __________________________

Commission expiry: ____. Changes can be made anytime by the Decision Maker. Use chart below or print new agreement for more amendments.

Amendments: record date, change details, signatures. Repeat for multiple changes as needed. Cancellations Decision Maker or Supporters can cancel anytime; prior decisions/actions remain valid.

Cancelled supporters: record date, name, signature for each supporter (1-3). Page 33 of 47 DBHDS SDMA Draft Sample DBHDS SDMA Draft Sample Discovery Tools These three (3) tools can be used to gather helpful information when creating a Supported Decision-Making Agreement. These include 1) When Do I Want Support? tool, 2) What Kind of Support Do I Want? tool, and 3) Relationship Map tool.

Page 34 of 47 Commonwealth of Virginia: Supported Decision-Making Discovery Tool Adapted from ACLU and PEATC resource on support needs.

Page 1 of 10 When do I want support? Everyone may need support with decisions, like from doctors, mechanics, or friends. This is called Supported Decision-Making.

Use this form to fill out Virginia’s Supported Decision-Making Agreement. Check boxes for own, supported, or others' help. Not all areas require checks.

If supporting, consider who and what support you want. Use attached tools for help.

I can do this alone.

I can do this with support.

I need help from someone else.

Health and Personal Care Get my health care information.  Choose when to go to the doctor.  Make and keep my doctor and dentist appointments.  Understand and make medical choices in serious situations (for example, surgery, big injuries).  Understand and make medical choices in an emergency.  Page 35 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 2 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Health and Personal Care- continued Understand and make medical choices in everyday situations (for example, check-up, getting medicine from the drug store).  Understand my medications, help remind me about my medications, and assist me in getting and taking my medications.  Understand personal hygiene, help remind me about my personal hygiene, and help me with my personal hygiene.  Choose what to wear and help me get dressed, if needed.  Decide where, when, and what to eat.  Make choices about drinking alcohol and using drugs.  Tell people what I want and what I don’t want regarding my health and personal care.  Tell people how I make choices about my health and personal care.  Make sure people understand what I am saying about my health and personal care.  Page 36 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 3 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Friends and Partners Understand and choose if I want to date and who I want to date.  Understand and make choices about birth control and pregnancy, and access medical care, if needed.  Make choices about sex.  Make choices about marriage.  Choose who to spend time with.  Tell people what I want and what I don’t want regarding my friends and partners.  Tell people how I make choices about my friends and partners.  Make sure people understand what I am saying about my choices and decisions regarding my friends and partners.  Page 37 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 4 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Money Get information about my finances.  Make big decisions about money (for example, opening a bank account, signing a lease).  Fill out financial forms and documents.  Keep a budget so I know how much money I can spend.  Pay rent and bills on time.  Make sure no one is taking my money or using it for themselves.  Tell people what I want and what I don’t want regarding my money.  Make sure people understand what I am saying about my choices and decisions regarding my money.  Page 38 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 5 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Where I Live and Community Living Get and look at information about places where I have lived.  Decide where to live.  Decide who to live with.  Understand chores, remind me to do chores, and help me do chores.  Understand any leases I am thinking about, and help me understand any rules of my home and community.  Make safe choices around the house (for example, turning off the stove, practicing for fire alarms).  Make decisions about what to do and where to go in my free time.  Make decisions about transportation, and help me use transportation.  Understand, find, hire, and fire support staff and services.  Make decisions about traveling to places I go often (for example, getting to stores, work, friends’ homes).  Page 39 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 6 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Where I Live and Community Living- continued Make decisions about traveling to places I do not go often (for example, special events, vacations).  Tell people what I want and what I don’t want regarding where I live and what I do in my community.  Tell people how I make choices about where I live and what I do in my community.  Make sure people understand what I am saying about my choices and decisions regarding where I live and what I do in my community.  School and Education Get and look at my education information and records.  Make decisions about whether to go to school, and where to go.  Make decisions about special education and accommodations.  Attend education meetings, including IEP meetings and school conferences.  Make decisions about school activities and events.  Page 40 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 7 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

School and Education- continued Tell people what I want and what I don’t want regarding my education.  Tell people how I make choices about my education.  Make sure people understand what I am saying my education.  Working Choose if I want to work.  Understand my work choices and apply for jobs.  Understand how working will affect my benefits (Social Security, Medicaid, etc.).  Understand the benefits I can have at work (vacation time, sick leave, time off, etc.).  Request benefits at work (vacation time, sick leave, time off, etc.).  Make decisions about transitional services (services as I transition out of high school).  Page 41 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 8 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Working- continued Explore and make decisions about internships, apprenticeships, and/or mentoring.  Make decisions about whether I need to take more classes or training to get a job I want, and help taking these classes.  Make decisions about supported employment or other supports and services I need in order to work.  Attend meetings with my employment supporters, including Vocational Rehabilitation or other employment agencies.  Make decisions about career preparation and placement.  Request accommodations for my work.  Get to and from work every day.  Talk to my employer.  Tell people what I want and what I don’t want regarding my work and work related supports.  Tell people how I make choices about my work and work related supports.  Page 42 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 9 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Working- continued Make sure people understand what I am saying about my work and work related supports.  My Rights and Safety Understand my rights as a voter and register to vote.  Understand my choices when voting at elections.  Cast my ballot when voting.  Understand and sign contracts and formal agreements.  Understand and get help if I am being treated badly (abuse, neglect, exploitation, undue influence, manipulation).  Communicate to others and make sure people understand what I am saying in regards to my rights and issues of safety.  Meeting and Talking with My Supporters Contact my Supporters to set up meetings.  Talk with my Supporters when I am upset or have a problem with them.  Page 43 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from Supported Decision-Making – When Do I Need Support? A Resource Document, developed by the American Civil Liberties Union (ACLU) and the Parent Educational Advocacy Training Center (PEATC).

Page 10 of 10 I can do this on my own.

I can do this with support.

I need someone else to do this for me.

Meeting and Talking with My Supporters- continued Keep my Supporters updated on how I am doing.  Keep my Supporters updated on what I am doing.  Communicate to my Supporters to make sure they understand what I am saying.  Other Choices or Activities Page 44 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool This document was adapted from How to Make a Supported Decision-Making Agreement, A Guide for People with Disabilities and their Families, developed by the American Civil Liberties Union (ACLU).

Page 1 of 2 What support do I want? Help varies per person and activity.

You can use this form to help you think about the different ways people can help and how you might want your Supporters to help you. Place a check () in the box next to each type of help you think you might want or need.  Have help filling out/writing on forms, such as my Supported Decision-Making Agreement.

Have information written and/or spoken in simple words (plain-language).

Have information provided in pictures.  Talk to your Supporters to know what your choices are.  Research to learn more about your choices on your own or with help from your Supporters.  Talk to experts (people who know a lot about your choices) about your options and choices.  Talk to your Supporters to get advice.

Page 45 of 47 Types of Support; refer to support options and resources.

Page 2 of 2 Types of Support Take extra time to think about your choices.  Get help making a pros and cons list (a list of good and bad sides of each choice).  Have Supporters remind you about your values (what is most important to you) and how these might impact your choices.  Help trying out different choices to see how you feel and which choice you like.

Supporters help communicate your choices.

Use technology (a phone or computer) to help communicate your choice to others.  Receive reminders about important dates and times.  Have a Supporter come to meetings and appointments with you.

Take classes (on-line or in person) to help learn more about choices.

Page 46 of 47 DBHDS SDMA Draft Sample Commonwealth of Virginia: Supported Decision-Making Discovery Tool The Relationship Map is a Person Centered Thinking tool developed by The Learning Community for Person Centered Practiced.

Supporters and Decision Makers form Supported Decision-Making Agreements; you choose anyone to support you in one or multiple areas.

When thinking about who you want as a Supporter, think about people that you trust and talk to them to see if they will agree to be your Supporter.

You can use this form to help you think about the different people who already help you in your life.

Your name goes in the center circle. Write the names of the people who help you in the category that best fits them. People who you feel closest to will go in the circle closest to your name. People that you do not feel as close to or that you do not look to for help as often can go in the outer circle. ______Sam’s Relationship Map Family People who support me at work or school.

People who support me at home and other places.

Friends Sam April Dad Mom Uncle Bill Aunt Sue Grandma Grandpa Ms. Schwartz (teacher) Ms. Jones (vo. Tech) Mr. Dunn (counselor) Adam Cara Paul Melanie Mike Kim David Mark Sarah Rachael (ABA therapist) Johnny (Theater Coach) Dr. Taylor (PCP) DBHDS SDMA Draft Sample Page 47 of 47

DBHDS, OHR 01, February 2024 Page 1 of 5

DBHDS Office of Human Rights (OHR) Reporting Peer-on-Peer Aggressions as Potential Neglect

Effective: 02/01/2024

This guidance is intended to clarify the reporting requirements to the DBHDS Office of Human Rights (OHR) for peer-on-peer aggressions that occur in community provider settings licensed or funded by DBHDS. It is intended to supersede guidance dated June 15, 2017, entitled “Office of Human Rights Peer-to-Peer Reportable Incidents.” The impetus for clarification was a comprehensive review of neglect data entered by providers in the DBHDS Computerized Human Rights Information System (CHRIS), and collaborative conversations with key stakeholders.

Defined Terms (See 12VAC35-115-30.) “Complaint” means an allegation of a violation of this chapter [the Regulations to Assure the Rights of Individuals Receiving Services from Providers Licensed, Funded, or Operated by the Department of Behavioral Health and Developmental Services (“Human Rights Regulations”) or a provider’s policies and procedures related to the Human Rights Regulations.

“Allegation” is not a defined term in the Human Rights Regulations; however, for purposes of this guidance and in practice, it is used interchangeably with the term “complaint” and refers to a claim or report of an alleged human rights violation.

“Individual” means a person who is receiving services. The term includes the terms “consumer”, “patient”, “resident”, “recipient” and “client”. In this document an individual is also referred to as a “peer.” See § 37.2-100 of the Code of Virginia.

“Internal review” is not a defined term in the Human Rights Regulations; however, when used in this guidance, it refers to the provider’s standard processes to review incidents to determine any further actions needed to identify and address potential harms to an individual and to reduce the likelihood of reoccurrence. Providers should have policies to address internal review procedures that include a reasonable timeframe for the review of incidents, the methodology used for the review, and a structure for documenting the outcome of the review.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See DBHDS, OHR 01, February 2024 Page 2 of 5 § 37.2-100 of the Code of Virginia. Neglect directly impacts the health and safety of an individual receiving services and has the potential to result in significant harm to the individual.

“Peer-on-peer aggression,” for purposes of this guidance, means a physical act, verbal threat, or demeaning expression by an individual against or to another individual that causes physical or emotional harm to that individual. Examples include hitting, kicking, scratching, and other threatening behavior.

Note: Incidents involving peer-on-peer aggression may constitute potential neglect when provider staff fail to follow internal policies and procedures, do not deliver supervision consistent with an individual’s individualized services plan (ISP), or do not act to prevent an individual from being harmed during the incident. Physical harm resulting from peer-on-peer aggression may be evidenced by open wounds, bruises, black eyes, lacerations, or broken bones. Emotional harm resulting from peer-on-peer aggression may be evidenced by an individual stating that they are feeling unsafe or afraid of certain peers, or documented changes in the individual’s behavior (i.e., becoming more withdrawn, avoidance of peer(s), or clinical documentation from a qualified professional).

“Provider” means any person, entity, or organization offering services that is licensed, funded, or operated by the department. See § 37.2-403 of the Code of Virginia.

“Serious injury” means any injury resulting in bodily hurt, damage, harm, or loss that requires medical attention by a licensed physician, doctor of osteopathic medicine, physician assistant, or nurse practitioner. See 12VAC35-115-30.

"Services" means care, treatment, training, habilitation, interventions, or other supports, including medical care, delivered by a provider licensed, operated, or funded by the department. See § 37.2-403 of the Code of Virginia.

Background Historically, the standard for reporting incidents of peer-on-peer aggressions to the OHR in CHRIS emphasized the occurrence of the incident in combination with either a complaint or provider suspicion of neglect. The rationale was that requiring providers to report incidents of peer-on-peer aggressions where they “suspect” neglect, even in the absence of an actual complaint alleging neglect, increased the department’s ability to monitor provider trends and ensure appropriate actions to prevent and mitigate harm of individuals. However, the requirement to report on this basis did not fully validate the fact that incidents of peer-on-peer aggressions can and do occur when neglect is not present. It also deemphasized the fact that providers are ultimately responsible for identifying, monitoring, and mitigating risk patterns and trends. (See 12VAC35-105-520.)

In Fiscal Year 2022, licensed community providers reported a total of 8,708 complaints alleging neglect via CHRIS. Providers specifically coded 63% (5,542) of these complaints as alleged “Peer to Peer Neglect.” Of these “Peer to Peer Neglect” reports, less than 2% (121) were ultimately determined to be a violation of an individual’s right to DBHDS, OHR 01, February 2024 Page 3 of 5 be free from neglect while receiving services. The high volume of reports compared to the low number of substantiated neglect violations is an indication that the vast majority of peer-on-peer incidents of aggression are not the result of neglect. During the same time period, data on serious incidents reported via CHRIS to the DBHDS Office of Licensing indicate there were 513 incidents (out of 22,424) where the cause of the incident was peer-on-peer aggression. In addition to the above, the OHR became aware of another 300-plus complaints alleging neglect that were brought to its attention through means other than provider self-report.1 Of these other complaints, 15% should have been reported by the provider as alleged “Peer to Peer Neglect” under the current reporting guidance. This illustrates additional concerns about provider compliance with the existing reporting requirements.

The goal of the oversight provided by the OHR and the reporting requirements in the Human Rights Regulations is to enable the department to monitor compliance with relevant laws and regulations in order to help ensure the rights and safety of individuals receiving services. While notification to the OHR is a function of CHRIS, additional purposes include: 1) documenting alleged abuse, neglect, or exploitation, and other human rights complaints; 2) documenting a summary of the provider’s investigation, findings, and any corrective action; and 3) allowing for review, monitoring, and verification of corrective action by the OHR.

Therefore, providers should only report incidents to the OHR in CHRIS that are alleged to have resulted in a human rights violation, whether that complaint is by an individual receiving services, by provider staff, or by other people outside the provider agency.

Even when the outcome is known or predictable to the provider, a CHRIS report and investigation of circumstances is required for all complaints. A review of an incident where there is no complaint, identified pattern, or determination that a human rights violation may have occurred is not reportable to the OHR in CHRIS; however, these may still be reportable to the Office of Licensing if they meet the definition of a serious incident.

Internal Review of Peer-on-Peer Aggression All incidents that meet the definition of “peer-on-peer aggression” in the Human Rights Regulations are to be reviewed by the provider, in accordance with the providers policies and procedures. This internal review of incidents involving peer-on-peer aggression is expected to consider, at a minimum, whether provider staff followed internal policies and procedures, delivered supervision consistent with individual(s) needs and the ISP(s), and acted to prevent individuals from being harmed while receiving services. In addition, the provider is expected to identify any programmatic issues that may have contributed to the opportunity for peer-on-peer aggression (e.g., policies, protocols, etc.). Upon completion of this internal review, providers are expected to implement any identified proactive measures that may reduce the number of peer-on-peer aggressions and lessen the possibility of neglect, resulting in a safer treatment environment overall. (See also 12VAC35-105-160 and 12VAC35-105-520 of the Rules and Regulations for Licensing Providers by the Department of Behavioral Health and

1 These additional reports came to OHR’s attention through local departments of Social Services, the Office of the State Inspector General, and via the Office of Licensing online complaint process.

DBHDS, OHR 01, February 2024 Page 4 of 5 Developmental Services [“Licensing Regulations”] that specify various review and reporting requirements.) Please note that the internal review is separate from the investigation that would occur if the review raised suspicion of abuse or neglect, or if the provider received a complaint.

The OHR may request to review provider information specific to their review of incidents involving peer-on-peer aggression because of identified trends, the possibility of neglect, complaints discovered by the OHR that were known to the provider but not reported, or in any situation that the OHR deems necessary to protect the rights of individuals receiving services from providers of mental health, developmental, or substance abuse services in Virginia. (See 12VAC35-115-260.)

Reporting Peer-on-Peer Aggression as Potential Neglect Providers must report to the OHR all incidents of peer-on-peer aggression that are alleged to have resulted in or from a human rights violation, whether the alleged violation is discovered by the provider or through a complaint. These incidents of peer-on-peer aggression shall be entered in CHRIS within 24 hours of discovery of the incident or receipt of the complaint, in accordance with 12VAC35-115-230. These incidents should be coded under the category “Neglect Peer-on-Peer Aggression.”

Examples of incidents of peer-on-peer aggression that should be reported: :

 An incident that clearly occurred because staff were not engaged in appropriate supervision (e.g., provider staff willfully ignored the physical act, verbal threat, or demeaning expression of one peer to another; provider staff intervened but not in accordance with policy; provider staff failed to implement supervision or supports based on the specific needs identified in the ISP);

A pattern of three or more incidents of peer-on-peer aggression involving the same peers within a seven-day timeframe (e.g., Individual A was the victim of physical acts, verbal threats, or demeaning expressions by another individual or individuals during three or more separate incidents within the timeframe; Individual B performed physical acts, verbal threats, or demeaning expressions toward another individual or individuals during three or more separate incidents within the timeframe).

Entering Incidents of Peer-on Peer Aggression in CHRIS

Incidents of peer-on-peer aggression that are determined to be reportable after a review by the provider shall be entered in CHRIS within 24 hours of the date of this determination, which is the date of discovery. These incidents should be coded under the category “Neglect Peer-on-Peer Aggression” and the description must indicate the reason for the report. For instance, when the report is concerning three or more incidents of peer-on-peer aggression within a seven-day timeframe, the provider should indicate this as the “description,” along with a brief account of the three incidents. When the complaint alleges involvement of a known provider staff person, the provider staff name should be entered in the description of the incident on the Accusation Tab in CHRIS. If the complaint indicates a possible programmatic failure, the provider should select “Other” and enter the provider’s name (e.g., ABC Residential) under the Accusation Tab in CHRIS. Reports of peer-on-peer aggression should be entered in DBHDS, OHR 01, February 2024 Page 5 of 5 CHRIS under the name of the individual who was the alleged victim of the aggression. If the aggression was mutual, a separate report must be entered for all individuals involved.

All incidents of peer-on-peer aggression that are reported in CHRIS must be investigated in full accordance with the Human Rights Regulations. (See 12VAC35-115-175.) The complaint shall be substantiated when the provider determines, as a result of its investigation, that the incident of peer-on-peer aggression: (i) was the result of acts or omissions by provider staff or a programmatic deficit; and (ii) resulted in an individual’s physical or emotional harm. Providers are expected to take and document appropriate corrective actions for all substantiated complaints resulting in a human rights violation.

In addition to the provider’s reporting requirements to the department as outlined above, if at any time the provider has reason to suspect that an incident may be a crime, or is otherwise reportable to another entity, the provider shall report the incident to all appropriate authorities. Such instances include but are not limited to an incident:  Between peers involving sexual assault, which is a form of violence and includes forced groping and rape;  Involving unwanted sexual activity between minors (e.g., intercourse, kissing, touching of private areas); or Involving sexual intercourse or other sexual activity, physical assault, or exploitation between adult peers in which at least one individual is deemed to lack capacity based on an existing assessment that indicated the individual was at risk of exploitation.

DBHDS, OHR 01, February 2024 Page 1 of 5

DBHDS OHR Reporting Peer-on-Peer Aggressions as Potential Neglect

Effective: 02/01/2024

This guidance clarifies reporting to OHR for peer-on-peer aggressions in community provider settings licensed or funded by DBHDS, superseding June 15, 2017, guidance, following a review of neglect data in CHRIS and stakeholder discussions.

“Complaint” means an allegation of a violation of this chapter or provider policies related to the Human Rights Regulations, as defined in 12VAC35-115-30.

“Allegation” is used interchangeably with “complaint” in this guidance, referring to a claim or report of a human rights violation.

“Individual” means a person receiving services, also called “consumer”, “patient”, “resident”, “recipient”, “client”, or “peer” per § 37.2-100 of Virginia Code.

“Internal review” refers to the provider’s process to assess incidents, determine actions, and document outcomes, including policies on timeframe, methodology, and documentation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See DBHDS, OHR 01, February 2024 Page 2 of 5 § 37.2-100 of the Code of Virginia. Neglect directly impacts the health and safety of an individual receiving services and has the potential to result in significant harm to the individual.

“Peer-on-peer aggression” means physical acts, threats, or demeaning expressions causing harm, including hitting, kicking, scratching, or threatening behavior.

Peer-on-peer aggression may be neglect if staff fail to follow policies, supervise per ISP, or prevent harm. Physical harm includes wounds, bruises; emotional harm includes fear, withdrawal, or professional documentation.

“Provider” means any person, entity, or organization offering services that is licensed, funded, or operated by the department. See § 37.2-403 of the Code of Virginia.

“Serious injury” means any injury resulting in bodily hurt, damage, harm, or loss that requires medical attention by a licensed physician, doctor of osteopathic medicine, physician assistant, or nurse practitioner. See 12VAC35-115-30.

"Services" means care, treatment, training, habilitation, interventions, or other supports, including medical care, delivered by a provider licensed, operated, or funded by the department. See § 37.2-403 of the Code of Virginia.

Historically, reporting required incidents with a complaint or suspicion of neglect, but many peer-on-peer aggressions occur without neglect, and providers are responsible for monitoring risks, per 12VAC35-105-520.

In Fiscal Year 2022, licensed community providers reported a total of 8,708 complaints alleging neglect via CHRIS. Providers specifically coded 63% (5,542) of these complaints as alleged “Peer to Peer Neglect.” Of these “Peer to Peer Neglect” reports, less than 2% (121) were ultimately determined to be a violation of an individual’s right to DBHDS, OHR 01, February 2024 Page 3 of 5 be free from neglect while receiving services. The high volume of reports compared to the low number of substantiated neglect violations is an indication that the vast majority of peer-on-peer incidents of aggression are not the result of neglect. During the same time period, data on serious incidents reported via CHRIS to the DBHDS Office of Licensing indicate there were 513 incidents (out of 22,424) where the cause of the incident was peer-on-peer aggression. In addition to the above, the OHR became aware of another 300-plus complaints alleging neglect that were brought to its attention through means other than provider self-report.1 Of these other complaints, 15% should have been reported by the provider as alleged “Peer to Peer Neglect” under the current reporting guidance. This illustrates additional concerns about provider compliance with the existing reporting requirements.

OHR oversight aims to monitor compliance, document allegations, provider investigations, findings, corrective actions, and enable review and verification, with notifications via CHRIS.

Providers must report in CHRIS only incidents alleged to involve a human rights violation, by individuals, staff, or others outside the agency.

All complaints require CHRIS reporting and investigation, even if outcome is predictable. Incidents without complaints or violations are not reportable to OHR but may be to Licensing if serious.

All peer-on-peer aggression incidents must be internally reviewed per policies, assessing staff adherence, supervision, harm prevention, and contributing program issues. Providers must implement measures to reduce incidents and neglect risk.

Additional reports to OHR came from Social Services, Inspector General, and Licensing online complaints.

DBHDS, OHR 01, February 2024 Page 4 of 5 Developmental Services [“Licensing Regulations”] that specify various review and reporting requirements.) Please note that the internal review is separate from the investigation that would occur if the review raised suspicion of abuse or neglect, or if the provider received a complaint.

OHR may review provider info on peer aggression incidents due to trends, neglect risk, unreported complaints, or to protect individual rights, per 12VAC35-115-260.

Providers must report peer-on-peer aggression incidents alleging human rights violations in CHRIS within 24 hours, coded as “Neglect Peer-on-Peer Aggression.”

Examples of peer-on-peer aggression incidents requiring reporting:

Incidents due to staff neglecting supervision, ignoring acts, intervening improperly, or failing to support ISP needs.

A pattern of 3+ peer-on-peer incidents involving same peers within 7 days, either as victims or perpetrators.

Entering Peer-on-Peer Aggression Incidents in CHRIS

Incidents of peer-on-peer aggression that are determined to be reportable after a review by the provider shall be entered in CHRIS within 24 hours of the date of this determination, which is the date of discovery. These incidents should be coded under the category “Neglect Peer-on-Peer Aggression” and the description must indicate the reason for the report. For instance, when the report is concerning three or more incidents of peer-on-peer aggression within a seven-day timeframe, the provider should indicate this as the “description,” along with a brief account of the three incidents. When the complaint alleges involvement of a known provider staff person, the provider staff name should be entered in the description of the incident on the Accusation Tab in CHRIS. If the complaint indicates a possible programmatic failure, the provider should select “Other” and enter the provider’s name (e.g., ABC Residential) under the Accusation Tab in CHRIS. Reports of peer-on-peer aggression should be entered in DBHDS, OHR 01, February 2024 Page 5 of 5 CHRIS under the name of the individual who was the alleged victim of the aggression. If the aggression was mutual, a separate report must be entered for all individuals involved.

All peer-on-peer incidents reported in CHRIS must be fully investigated per 12VAC35-115-175. Substantiation requires staff acts/omissions or program deficits causing harm; corrective actions must be documented.

In addition to the provider’s reporting requirements to the department as outlined above, if at any time the provider has reason to suspect that an incident may be a crime, or is otherwise reportable to another entity, the provider shall report the incident to all appropriate authorities. Such instances include but are not limited to an incident:  Between peers involving sexual assault, which is a form of violence and includes forced groping and rape;  Involving unwanted sexual activity between minors (e.g., intercourse, kissing, touching of private areas); or Involving sexual intercourse or other sexual activity, physical assault, or exploitation between adult peers in which at least one individual is deemed to lack capacity based on an existing assessment that indicated the individual was at risk of exploitation.

Support Coordination

A HANDBOOK FOR

DEVELOPMENTAL DISABILITIES WAIVER SUPPORT COORDINATION June 2023 (Rev. July 2024) Adobe Acrobat Reader is recommended for viewing this handbook, which can be downloaded for free at https://get.adobe.com/reader/. When using this option, handouts and attachments can be opened in a new tab by selecting links using CTRL+click on your keyboard. Using this function enables easily returning to the same section in the handbook. i Table of Contents Introduction Terms Used .......................................................................................................................................................... 6 Virginia’s Public Behavioral Health and Developmental Services System ........................................................... 6 Chapter 1: Person Centered Practices ................................................................................................................. 9 Principles & Virginia’s Vision ................................................................................................................................ 9 Values & Practices .............................................................................................................................................. 11 Chapter 2: Support Coordination Overview ...................................................................................................... 17 Support Coordination ........................................................................................................................................ 17 Support Coordination for people with ID .......................................................................................................... 17 Support Coordination for people with DD ...................................................................................................... 18 Targeted Case Management (State Plan Option) .................................................................................. 20 Post Move Monitoring ...................................................................................................................................... 20 Role of family and friends, the use of a Supported Decision-Making Agreement, Powers of Attorney, Authorized Representatives and Legal Guardians ................................................................................................................ 21 Waiver Management System (WaMS) ...................................................................................................... 25 Appeal Rights .......................................................................................................................................... 25 Chapter 3: Qualifications ................................................................................................................................... 27 Centers for Medicare & Medicaid Services (CMS) Setting Regulations - HCBS ................................................. 27 Support Coordinator Qualifications ................................................................................................................... 29 Background and List of Excluded Individuals and Entities (LEIE) Checks........................................................... 30 Chapter 4: Support Coordination: Assessment and Intake .............................................................................. 31 How to Screen, Assess and Conduct an Intake .................................................................................................. 31 Documentation to Support Diagnosis of Developmental Disability (to include ID if applicable) – Eligibility .. 31 Consent to Exchange Information ..................................................................................................................... 32 Risk Awareness Tool .......................................................................................................................................... 33 Human Rights Notification ................................................................................................................................. 33 Determining Capacity ........................................................................................................................................ 33 Choice of Waiver/Intermediate Care Facility .................................................................................................... 33 Supports Intensity Scale (SIS) ............................................................................................................................ 35

1. 5.24 ii Physical Exam ......................................................................................................................................... 36 DMAS 460 Virginia Informed Choice Form (DMAS 460) ........................................................................ 36 DMAS 225 Medicaid Long Term Care (LTC) Communication Form .................................................................. 36 Chapter 5: Waiver Wait List and Slot Assignment............................................................................................. 37 Wait List ............................................................................................................................................................. 37 Priority Needs Checklist ..................................................................................................................................... 37 Critical Needs Summary .......................................................................................................................... 38 Right to Appeal ......................................................................................................................................... 39 DD Waiver Slot Allocation General Information ............................................................................................... 39 Waiver Slot Assignment Committee (WSAC) ............................................................................................ 39 Chapter 6: Developmental Disability Waiver & Services ................................................................................... 41 Introduction ....................................................................................................................................................... 41 Brief History of Developmental Disability Waivers ............................................................................................ 41 Description of Developmental Disability Waivers ............................................................................................. 42 Services in Waivers ............................................................................................................................................ 42 Assistive Technology .......................................................................................................................................... 42 Benefits Planning Services ................................................................................................................................. 43 Center-Based Crisis Supports ............................................................................................................................. 44 Community-Based Crisis Supports ..................................................................................................................... 44 Community Coaching ......................................................................................................................................... 45 Community Engagement ................................................................................................................................... 46 Community Guide .............................................................................................................................................. 46 Companion Services ........................................................................................................................................... 48 Consumer Directed Services Facilitation ........................................................................................................... 48 Crisis Support Services ....................................................................................................................................... 49 Electronic Home-Based Services ........................................................................................................................ 50 Employment and Community Transportation ................................................................................................... 50 Environmental Modifications............................................................................................................................. 50 Group Day Services ............................................................................................................................................ 51 Group Home Residential .................................................................................................................................... 51 Independent Living Support............................................................................................................................... 52 Individual and Family/Caregiver Training .......................................................................................................... 52
2. 5.24 iii In-Home Support Services ................................................................................................................................. 53 Peer Mentor Supports ....................................................................................................................................... 53 Personal Assistance ............................................................................................................................................ 54 Personal Emergency Response System ............................................................................................................. 55 Private Duty Nursing .......................................................................................................................................... 55 Respite ............................................................................................................................................................... 56 Shared Living ...................................................................................................................................................... 56 Skilled Nursing .................................................................................................................................................... 57 Sponsored Residential ....................................................................................................................................... 57 Supported Employment ..................................................................................................................................... 58 Supported Living ................................................................................................................................................ 58 Therapeutic Consultation .................................................................................................................................. 59 Transition Services ............................................................................................................................................. 59 Workplace Assistance ........................................................................................................................................ 60 Patient Pay ......................................................................................................................................................... 60 Review, Add, Change Service Providers ............................................................................................................ 65 Service Authorization ......................................................................................................................................... 65 Working with Managed Care Organizations (MCOs) Care Coordinators ......................................................... 66 Chapter 7 Support Coordination Process: Plan Development and Implementation ........................................ 67 Linking to Services .............................................................................................................................................. 67 Annual Eligibility Determination .............................................................................................................. 68 How to Utilize Assessment Information to Begin Plan Development ..................................................... 69 Parts of Virginia’s PC ISP ......................................................................................................................... 72 How to Write Measurable Outcomes .................................................................................................... 75 Plan for Supports Approval and Submission...................................................................................................... 76 Service Authorizations to Initiate Services............................................................................................... 76 How to Evaluate and Document Implementation of a PC ISP ................................................................. 76 Regional Support Teams .................................................................................................................................... 77 PC ISP Training Modules......................................................................................................................... 78 Chapter 8 Support Coordination Process: Monitoring Billable Activities and Evaluation ................................. 79 Support Coordination Timelines ........................................................................................................................ 79
3. 5.24 iv Ongoing Assessment/Monitoring .......................................................................................................... 80 Status of Current Risks and Identifying New Risks ................................................................................. 81 PC ISP Updates ...................................................................................................................................... 82 Face-to-Face Visits .................................................................................................................................. 83 Enhanced Case Management ................................................................................................................. 84 Chapter 9 - Support Coordination Process: Transitions of Support .................................................................. 86 Transfers between Support Coordinators Within the Same CSB ...................................................................... 86 Transfer Protocols to/from Other CSBs ............................................................................................................. 86 Discharge/Transition Planning ........................................................................................................................... 86 Chapter 10: Health & Safety .............................................................................................................................. 89 Support Coordinator’s Role in Health & Safety ................................................................................................. 89 Proactive Steps to Health ....................................................................................................................... 91 Medication and Side Effects .............................................................................................................................. 92 Eight Health Risks ................................................................................................................................... 92 Abuse, Neglect, and Exploitation ........................................................................................................... 99 Mandated Reporting ...................................................................................................................................... 100 Office of Licensing – CHRIS Serious Incident Reporting ....................................................................... 102 Office of Human Rights ........................................................................................................................ 103 Caregiver Stress and Burnout ............................................................................................................... 105 Chapter 11: Community Resources ................................................................................................................ 108 Chapter 12: Employment, Post-Secondary Opportunities and Integrated Community Involvement ............ 112 Impacts of Employment ................................................................................................................................... 112 Virginia’s Recognition of the Importance of Work .......................................................................................... 113 Role of the Support Coordinator.......................................................................................................... 114 Transportation Resources .................................................................................................................... 121 Misinformation about Employment and People with Disabilities ....................................................... 123 Additional Information about Benefits ............................................................................................................ 123 Employment Services under Waivers .............................................................................................................. 124 Integrated Employment Models ...................................................................................................................... 124 Benefits Counseling .......................................................................................................................................... 125
4. 5.24 v Chapter 13: Housing ........................................................................................................................................ 127 Support Coordinator’s Role in Integrated, Independent Housing .................................................................... 127 Support Coordinator Training, Resources and Tools ....................................................................................... 131 DBHDS Regional Housing Coordinators ........................................................................................................... 131 DBHDS Housing Resources ..................................................................................................................... 131 DBHDS Housing Referral Package ......................................................................................................... 133 Chapter 14: Reviews ........................................................................................................................................ 134 DBHDS Office of Licensing (OL) ........................................................................................................................ 135 DBHDS Office of Human Rights (OHR) ............................................................................................................. 135 Quality Service Reviews ................................................................................................................................... 135 National Core Indicators (NCI) ......................................................................................................................... 136 Department of Medical Assistance Services (DMAS) Reviews ........................................................................ 136 Support Coordinator Quality Reviews (SCQR) ................................................................................................ 137 Department of Justice (DOJ) Settlement Agreement Independent Reviewer ................................................ 138 Chapter 15: Forms ............................................................................................................................................ 139

DBHDS ............................................................................................................................................................ 139 DMAS ............................................................................................................................................................. 139 Housing ............................................................................................................................................................ 139 Individual and Family Support ......................................................................................................................... 139 PC Individual Support Plan ............................................................................................................................... 140 Medical ............................................................................................................................................................. 140 Person-Centered Review…. .............................................................................................................................. 140 Resources…………………………………………………………………………………………………………………………………………………..140 Support Intensity Scale ................................................................................................................................... 140 Supported Decision-Making ............................................................................................................................ 140 Training ............................................................................................................................................................ 141 Virginia Informed Choice ................................................................................................................................. 141 Waivers ............................................................................................................................................................ 141 Waiver Slot Assignment Committee ................................................................................................................ 141 Other ................................................................................................................................................................ 142

1. 5.24 6 Target Audience Support coordination/case management is the core service that Virginians with developmental disabilities use to help navigate and make the best use of Virginia’s publicly funded system of services. This service is of critical importance in all dimensions of the services system. Strengthening the support coordinator’s/case manager’s role is essential to ensuring effective and accountable services within the Medicaid Home and Community-Based Services Development Disability (DD) Waivers. The purpose of this handbook is to guide support coordinators in all aspects of their work with people who have a Developmental Disabilities Waiver.

Terms Used in Handbook Although the terms “support coordinator” (SC), “case manager” (CM), and even “services coordinator” may be used interchangeably, support coordinator is the term most frequently used in regulations and in most of the material and guidance related to developmental disability support coordination/case management services developed by the Virginia Department of Behavioral Health and Developmental Services (DBHDS).

Therefore, support coordinator (SC) and support coordination will be used throughout this handbook. There is a glossary of terms and their acronyms used in this handbook.

Virginia’s Public Behavioral Health and Developmental Disability System DBHDS supports individuals needing or receiving services by promoting recovery, self-determination, and wellness in all aspects of life. DBHDS’ vision statement is, “A life of possibilities for all Virginians.” DBHDS oversees supports and services for Virginians with developmental disabilities (DD), mental illness (MI)s, and substance use disorders (SUD), and manages day to day operations for the DD Waivers.

The state agency that administers the DD Waivers in Virginia is the Department of Medical Assistance Services (DMAS). Locally, DD Waiver services are coordinated by SCs employed by or contracted through 40 agencies that are referred to as either community services boards (CSBs) or behavioral health authorities (BHAs). The actual services are delivered by CSBs/BHAs and private providers across the Commonwealth.

Use of this Handbook This handbook is divided into chapters and sub-chapters. If you wish to go to a particular chapter or sub-chapter listed, you can click on that topic in the Table of Contents and it will take you to the appropriate page.

Introduction

1. 5.24 7

The following are entities that guide, inform, and support the role of the Support Coordinator:

• State Structure chart: The Big Picture
• Department of Behavioral Health & Developmental Services
• Departments and people to know from the DBHDS o Community Resource Consultants (CRC): The CRCs help guide SCs with problem solving and offer training and consultation. o Regional Support Specialists (RSS): The regional support unit (RSU) oversees management and implementation of the DD Waivers Waitlist by CSBs, as well as all aspects of waiver slot assignments through the Waiver Slot Assignment Committee (WSAC) process. o Service Authorization Consultants (SAC): The SACs authorize requested waiver services. o REACH (Regional Education Assessment Crisis Services Habilitation):

REACH provides crisis stabilization, intervention, and prevention services. o Regional Support Teams (RSTs): RSTs provide recommendations in resolving barriers to the most integrated community settings consistent with a person’s needs and informed choice. o Office of

Integrated Health (OIH): OIH

ensures quality supports and community integrated health services by

building and improving new, innovative ways to

effect change, and decrease o

inter- and intra-departmental barriers across agencies. o Regional Housing Specialists:

Housing specialists are responsible for developing local, regional, and statewide relationships and for identifying potential resources necessary to increase the availability of and access to affordable and accessible housing for individuals with a developmental disability who are Medicaid Waiver recipients or those who are eligible for a Medicaid Waiver and possibly on the Waiver waiting lists (“target population”). o Office of

Licensing (OL):

OL licenses providers that provide treatment, training, support, and habilitation to those with mental illness, developmental disabilities, or substance use disorders; to people using services under the Medicaid DD Waivers; or those with brain injuries who use services in residential facilities. o Office of

Human Rights (OHR):

OHR works to ensure and protect the human rights of individuals who use services in DBHDS state facilities or programs operated, licensed, or funded by DBHDS.

A Brief History of

Department of

Justice Settlement Agreement in

Virginia In August 2008, the Department of Justice (DOJ) initiated an investigation of Central Virginia Training Center ( CVTC) pursuant to the Civil Rights of Institutionalized Persons Act (CRIPA). In April 2010, DOJ notified the Commonwealth that it was expanding its investigation to focus on Virginia’s compliance with the Americans with Disabilities Act (ADA) and the U.S. Supreme Court Olmstead ruling. The Olmstead decision requires that people be served in the most integrated settings appropriate to meet their needs consistent with their choice.

In February 2011, DOJ submitted a findings letter to Virginia, concluding that the Commonwealth failed to provide services to those with intellectual and developmental disabilities in the most integrated setting appropriate to their needs.

In March 2011, upon advice and counsel from the Office of the Attorney General (OAG), Virginia entered into negotiations with the DOJ in an effort to reach a settlement without subjecting the Commonwealth to an extremely costly and lengthy court battle with the federal government.

1. 5.24 8 On January 26, 2012, DOJ reached a settlement agreement with Virginia. Compliance with the Agreement resolves DOJ’s investigation of Virginia’s training centers and community programs and the Commonwealth’s compliance with the ADA and Olmstead with respect to individuals with intellectual and developmental disabilities. See the DOJ Settlement Agreement.
2. 5.24 9 Definition “Person-centered practices” is a term that embodies values and skills used to support and interact with people . Although the term is often used in conjunction with the developmental disability field, person- centered practices are in fact about people and are used in many different settings and areas of support need. This chapter describes the values that underlie all person-centered practices. Specific tools and skills are abundant and varied. The Person- Centered Practices At-a-Glance resource page found at the end of this chapter provides links to training and websites to learn specific person-centered skills and obtain person- centered tools.

Person-centered practices encourage interaction with people with disabilities in much the same way as with people who do not have disabilities. People with disabilities have the same wants and needs as anyone else.

Their needs are not ‘special.’ Like most of us, people with disabilities want to feel a sense of belonging, they want to make contributions, feel useful and productive, love and be loved, and govern their own lives, including where and with whom they work, live, and play. People with disabilities are valuable members of the community. Those persons who provide supports, including support coordinators, focus on promoting rich and fulfilling lives in the community.

Principles & Virginia’s Vision Virginia’s vision includes all people, not just those who use the service system. The vision centers on a Virginia where individuals of all ages and abilities have the supports needed to enjoy the rights of life, liberty, the pursuit of happiness, and the opportunity to have a good life.

This vision includes the idea that all people have the opportunities and supports needed to live a good life in their own homes and communities and that a good life is best led by the voice of the individual and by following these Person-Centered principles: Principles of Practice Principle 1: Listening - People are listened to and their choices are respected.

Principle 2: Community - Relationships with families and friends and involvement in the community are supported.

Principle 3: Self-Direction - People have informed choice and control over decisions that affect them.

Principle 4: Talents and Gifts - People have opportunities to use and share their gifts and talents.

Principle 5: Responsibility - There is shared responsibility for supports and choices.

CHAPTER 1: Person-Centered Practices

1. 5.24 10 This broader vision includes having a system of supports and services through which people with disabilities have opportunities for freedom, equality, and the opportunity to participate fully in their communities. How a person participates in the community is defined by the person, based on what is important to that person.

In this system, people with disabilities…

• Set their schedules, make decisions about how and where they live, and have opportunities for recreation that reflects their personal desires and interests;
• Access their communities with the same opportunity as people without disabilities;
• Are employed, which increases integration and enables the pursuit of interests through increased income;
• Have access to benefits counseling and financial planning services;
• Routinely spend time with friends, family, and others not paid to support or provide services to them;
• Have access to home ownership or tenancy rights in affordable, integrated settings where they live with whom they choose;
• Have knowledgeable, Person-Centered supports to explore and identify services and resources that lead to integration;
• Have dependable transportation for community access when needed and desired; and
• Choose their healthcare providers and have access to supports and activities that promote health, wellness, and safety.

Important to and Important for At the core of all Person-Centered practices is the ability to discover what is important to a person while balancing this with what is important for them. This is true about all people, not just those with a disability.

All of us have things in our lives that are important to us and important for us. We all struggle to strike a balance between doing things that are good for our health/safety and having things in our lives that we cherish or that just comfort us. Having what is important to us helps all of us handle stressors and issues that weigh on us. We all benefit from a sense of belonging, a sense of worth, and a sense of competence.

Important To Those things in life which help us to be satisfied, content, comforted, fulfilled, and happy. They include:

• People to be with/relationships
• Status and control
• Things to do
• Places to go
• Rituals or routines
• Rhythm or pace of life

• Things to have Important For Those things that keep a person healthy and safe. They include:

• Prevention of illness

1. 5.24 11

• Treatment of illness/medical conditions
• Promotion of wellness (e.g. diet, exercise)
• Issues of safety: in the environment, physical and emotional well-being, including freedom from fear Important For also includes what others see as necessary for a person to:
• Be valued.
• Be a contributing member of their community.

Promises of Person-Centered Practices According to the International Learning Community for Person-Centered Practices, there are inherent promises made to each person when supporting them using Person-Centered practices.

A Promise to listen

• To listen to what is being said and to what is meant by what is being said.
• To keep listening.

A Promise to act on what we hear

• To find something that we can do today or tomorrow.
• To keep acting on what we hear.

A Promise to be honest

• To let people know when what they are telling us will take time.
• When we do not know how to help them get what they are asking for.
• When what the person is telling us is in conflict with staying healthy or safe and we can’t find a good balance between what is important to and important for the person.

Values & Practices Respect The term “respect” has many types of meanings. It includes a positive feeling towards another person or the person’s skills, opinions, or other characteristics, and the honoring of a person’s beliefs, ideas, or culture.

Respect requires seeing a person as a whole not as a disability. As a SC, respect may be demonstrated by:

• Listening;
• Developing an understanding of a person’s background and their hopes and dreams;
• Presuming competence when meeting with and interacting with a person with a disability maintaining high expectations;
• Practicing cultural agility and humility;

1. 5.24 12

• Using everyday language;
• Supporting a person’s dreams;
• Recognizing a person’s talents and gifts; and
• Facilitating the ways a person can contribute to their community.

Being Culturally Aware We are all multi-faceted human beings. For the people an SC supports, disability is just one part of who they are.

SCs should remember to acknowledge and consider every person’s varied and unique rituals, routines, values, morals, and culture. Being culturally aware is about giving careful consideration to one’s own assumptions and beliefs that are embedded in one’s goals for a person.

The most important thing SCs can do to become more culturally aware is to understand their own cultures and assess their natural biases (the lens through which they view their world). Discuss with your supervisor if there are any agency resources that might help support cultural awareness.

Communication A SC will meet people who may communicate in different ways. It may sometimes be assumed a person is not communicating because they do not use words to talk. The truth is that everyone communicates in some way.

All people have the need to communicate to express choice, feelings, needs, likes and dislikes. Just because someone does not speak with words it doesn’t mean they don’t have something to say!

Communication is an exchange of ideas between people through a system of words, signs, or behaviors like gestures, body language, and actions. Some people use words to communicate, however, we do not use words alone to get our ideas across. We also employ behaviors to communicate, such as facial expressions (smiles, frowns, eye blinking), pointing or other physical gestures, vocal sounds, eye contact, and body movements. A number of studies have been conducted to understand what percent of human communication is non-verbal. While the studies disagree on an exact percentage, all agree that most communication is nonverbal. In fact, nonverbal behavior is the most crucial aspect of communication. Although some people may not use words to communicate, it does not mean that they cannot understand what others are saying.

Communication Considerations The SC and the CSB/BHA should communicate effectively and convey information in a manner that is easily understood by diverse audiences including:

• Persons who have limited English proficiency;
• Those who have low or no literacy skills; and
• Those whose disabilities limit their ability to communicate in typical ways.

Remember that SCs have a responsibility to support individuals no matter what language they speak. If needed, ask a supervisor how to access interpreters or other supports.

1. 5.24 13 Use of Everyday Language How support coordinators talk with and about people with disabilities will influence the attitudes and interactions others have with people with disabilities. Choice of words in speaking and attitudes conveyed through tone of voice are very important. Language can create a barrier when a SC uses “special” language or professional jargon when talking to or about people with disabilities. Special language says people with disabilities are different and sets up an “us” versus “them” dynamic. Using words like “client” or “consumer” depersonalizes people. Instead, use everyday language, words, and phrases you would use when talking about co-workers, friends, and family members. Some examples: “Person First” language emphasizes the person and not the disability. The first choice is always to call someone by name. If the situation dictates that the disability must be mentioned, always put the person first.

The phrase, “a disabled person” can be disrespectful and emphasizes the disability rather than the person. A SC should say, “a person with a disability.” Instead of saying “someone with Down’s,” say, “a person who has Down syndrome.” Referring to the person first lets others know that he or she is, first and foremost, a person who deserves respect.

SCs need to also be aware of a person’s individual preferences as well. There are some people with disabilities who do not prefer person first language. For example, some people who are on the autism spectrum may prefer to be referred to as ‘autistic’ rather than ‘a person with autism’. They assert that autism is part of them, and they cannot be separated from their autism as it might be with a person being cured of a disease.

Therefore, they prefer to be called “autistics” to identify that this diagnosis and way of being is an important part of their identity. In instances such as these, it is important to respect and use the language an individual person prefers. To read more, visit Autism Mythbusters.

According to the International Learning Community for Person-Centered Practices, “How you say what you say matters as much as the actual words you say.” Some other things to keep in mind regarding language are:

• Tone - The inflection or emotion in your voice. It should be age appropriate (no baby talk for adults), mild, and respectful.

Instead of this ….

Say this….

Client, consumer Person, the person’s name My caseload, my clients, my guys The people I support John was placed in a job John found a new job Jane transitioned from high school Jane graduated I did an ISP on someone I did an ISP with someone Ed needs support with toileting Ed needs support using the restroom I transported Amy I drove Amy Non-verbal Does not speak with words He is a Level 2/Tier 2 He is assigned to Level 2 Refused Chose not to Waiver individual Someone who has a waiver slot

1. 5.24 14

• Volume - Loudness of your voice. It should be appropriate for the situation. If you are in a noisy location, you may have to speak louder (not yell) to be heard. It can also be effective to lower the volume of your voice to draw someone’s attention.
• Context - Where are you? Is it a comfortable, familiar location? Who else is around? Privacy is important. What is the intensity of emotion being expressed? Are you or others upset, frustrated, sad, happy, etc.?
• Body Language - Gestures and movements that accompany the words. Some experts say that 75% to 90% of perceived language is body language. Body language such as crossing your arms can show disinterest. Shaking your finger at a person can show anger. Rolling your eyes can show disbelief. You want your body language to match with what you are saying, your intent, and how you are saying it.

Always remember that language reflects values – using respectful and person-centered language shows that a person truly is respectful of the people they support.

Personal Choice and Decision Making Personal choice means making decisions about all the details of our lives. Each day, as soon as we wake up, we are engaged in making choices. We ask ourselves: “Should I hit the snooze button or get up?,” “Should I call in sick or go to work?,” or “What should I wear?” We also make major decisions about who to live with and what sort of work we want to do. We are in control and it feels good to be empowered and able to make our own decisions. Everyone is entitled to make decisions about their lives. However, it is rare that anyone makes major decisions in their lives in isolation from others. Most of us talk with those we are close to when making major decisions. SCs play a significant role in promoting choice when planning with a person and when evaluating whether a plan is working for them. Efforts should be made to also include others in decision-making, if the person chooses to do so. Individual choice drives the formulation of outcomes on the Individual Support Plans, the way provider agencies operate, the staffing patterns (what staff do and when they do it), and the daily actions of the direct support professionals. Choice should occur naturally and should be expected without unnecessary restrictions. Many people entered supportive services with little to no choice. It is the SCs responsibility to promote personal choice by noticing likes, dislikes, and opinions as forms of choice. “Informed choice” refers to one’s ability to make a decision based on a clear understanding of the facts, results of the choice, and possible future consequences. Some people do not show the capacity for informed consent and need supports from family members, an authorized representative, or a legal guardian. This is typically reserved for decisions or choices that might have an effect on a person’s health and safety. This does not mean that the day-to-day choices or expression of hopes and dreams should be restricted. Additionally, capacity can be increased through the use of Supported Decision-Making. Supported Decision-Making should be explored first before more restrictive forms of support, such as a legal guardians.

Dignity of Risk The concept of “dignity of risk” is the right of a person to engage in experiences meaningful to them and that are necessary for personal growth and development. Life includes risks for everyone. Choice inherently involves risk, sometimes in a menial way; in other instances, in life threatening ways. Overprotecting people

1. 5.24 15

with disabilities keeps them from many life situations that they have the right to experience, and it may prevent meaningful connections and fulfillment of their hopes and dreams. Rather than protecting people with disabilities from disappointments and sorrows, which are natural parts of life, it is important to support them to make informed decisions. This enables them to experience the possibility of success and the natural risk of possible failure. Occasionally, a SC may believe they know the outcome for those who “dream too big.” Dignity of risk demands we try to help people explore and try and reach for their dreams.

Individual Rights All people have basic human rights. All people, including people with disabilities, are entitled to enjoy rights and freedoms to privacy, to have personal possessions, to marry, to exercise free speech, to live in neighborhoods, to complain, to vote, etc. It is also every person’s right to be free from abuse, neglect, and exploitation, and not to have restrictions on those rights and freedoms. Some people the SC supports may have had their legal rights limited through the appointment of a guardian, conservator, or another legal process. This does not mean they cannot make day-to-day choices and decisions or should have their dreams or plans go unheard. It is the SC’s responsibility to seek guidance and help with decision-making when appropriate or needed to preserve the health and safety of the person. As an employee of a community agency providing supports to people with developmental disabilities, it is the SC’s responsibility to be knowledgeable of the Regulations to Assure the Rights of Individuals Receiving Services from Providers Licensed, Funded or Operated by DBHDS (the “Human Rights Regulations”) [12VAC35-115].

Confidentiality Confidentiality is a right to privacy and respect of information given to and shared among professionals about people. People generally expect that their medical records, financial records, psychological records, criminal records, driving records, and other personal records are going to be kept in a confidential manner. SCs must remember to have this same respect for the private information about those they support. This includes health information that is covered by the Health Insurance Portability and Accountability Act (HIPAA) and substance use information that is more stringently covered under 42 CFR, Part 2. Each agency should provide additional information about confidentiality and requirements related to sharing information.

Person-Centered Practices Resources Life Course Tools Person-Centered Thinking Training in Virginia Support Development Associates Helen Sanderson Associates The International Learning Community for Person Centered Practices Cornell University Person-Centered Planning Education Site

1. 5.24 16 A Checklist for Person Centered Information Gathering and ISP Development Mary Lou Bourne 2008.

A Guide for Developing Preliminary Essential Lifestyle Plans: Conversation with the Person with Whom You are Planning Smull & ASA 2001 link at.

A Guide for Developing Preliminary Essential Lifestyle Plans: Conversations with Family and Support Services Smull & ASA 2001.

Read about Myths and Misconceptions about Person-Centered Planning pages 69 through 73.

1. 5.24 17 Support Coordination Support coordination is the core service that many Virginians with DD depend upon to help navigate and make the best use of our publicly funded system of services. In some ways SCs are the most important staff members in our entire system! They make sure individuals have access to services and ensure that those services are effective. When a need has been identified, SCs take the lead in problem solving and advocating for the people they support. SCs either work directly for a CSB/BHA or contract with one.

Although support coordination is not a DD Waiver service, it is required for all DD Waiver recipients and paid for by Medicaid.

There are two kinds of support coordination, one for people with ID and one for all others who have DD but not an ID diagnosis. They have different qualifications but have the same general expectations.

Support Coordination for people with ID DMAS regulations define “support coordination” for people with ID as: 12VAC30-50-440. Support coordination/Case management (support coordination) for individuals with an intellectual disability (ID). The target group is Medicaid-eligible individuals with an intellectual disability as defined in state law (§ 37.2-100 of the Code of Virginia).

Targeted support coordination services are defined as services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services.

1. An individual receiving ID support coordination shall mean an individual for whom there is an individual support plan (ISP) in effect that requires direct or individual-related contacts or communication or activity with the individual, the individual’s family or caregiver, service providers, and significant others. Billing can be submitted for an individual only for months in which direct or individual-related contacts, activity or communications occur consistent with the ISP.
2. There shall be no maximum service limits for support coordination/case management services except as related to individuals residing in institutions or medical facilities. For these individuals, reimbursement for support coordination/case management shall be limited to 30 days immediately preceding discharge. Support Coordination/case management for individuals who reside in an institution may be billed for no more than two pre-discharge periods within twelve months.

CHAPTER 2:

1. 5.24 18 Additional Considerations per Support Coordination for people with DD 12VAC30-50-490 Support coordination/case management (support coordination) for individuals with developmental disabilities.

The target group is Medicaid-eligible individuals with DD (other than ID) or related conditions as defined in state law (§ 37.2-100 of the Code of Virginia) who are on the waiting list or are receiving services under one of the DD Waivers. This target group shall be eligible for support coordination.

1. An individual receiving DD Support Coordination shall mean an individual for whom there is a Person-Centered Individual Support Plan (PC ISP) in effect which requires monthly direct or in-person contact, communication or activity with the individual and family/caregiver, as appropriate, service providers, and other authorized representatives including at least one face-to-face contact between the individual and the Support Coordinator/Case Manager every 90-days. Billing shall be submitted for an individual only for months in which direct or in-person contact, activity or communications occur and the Support Coordinator's/Case Manager's (SC) records document the billed activity. Service providers shall be required to refund payments made by Medicaid if they fail to maintain adequate documentation to support billed activities.
2. 5.24 Per "Intellectual disability" means a disability, originating before the age of 18 years, characterized concurrently by (i) significant subaverage intellectual functioning as demonstrated by performance on a standardized measure of intellectual functioning, administered in conformity with accepted professional practice, that is at least two standard deviations below the mean and (ii) significant limitations in adaptive behavior as expressed in conceptual, social, and practical adaptive skills. 37.2-100 of the Code of Virginia 12VAC30-50-440 The unit of service is one month.

Activities include: Assessment and planning services Linking the individual to services and supports specified in the ISP Assisting the individual directly for the purpose of locating, identifying, or obtaining needed services/resources Coordinating services and service planning with other agencies and providers involved with the individual Enhancing community integration by contacting other entities to arrange community access and involvement Making collateral contacts to promote implementation of the ISP and community integration Following up and monitoring to assess ongoing progress and ensuring services are delivered Education and counseling that guides the individual and develops a supportive relationship that promotes the

ISP

• 19

1. Individuals who have developmental disabilities as defined in state law but who are on the DD waitlist for waiver services may receive Support Coordination/Case Management services only if there is a special service need identified, in which case an ISP shall be developed to address the special service need. In this case, the Support Coordinator/Case Managers shall make face-to-face contact with the individual at least every 90 calendar days to monitor the special service need, and documentation is required to support such contact. A special service need is one that requires linkage to and temporary monitoring of those supports and services identified in the ISP to address an individual's mental health, behavioral, and medical needs or provide assistance related to an acute need that coincides with the allowable activities noted in subsection D of this section. If an activity related to the special service need is provided in a given month, then the support coordinator/case manager would be eligible for reimbursement. Once the special service need is addressed related to the specific activity identified, billing for the service shall not continue until a special service need presents again.

Virginia uses the definition set forth by the federal Developmental Disabilities Act (42 USC Ch. 144). § 37.2-100 of the Code of Virginia : ”Developmental disability” means a severe, chronic disability of an individual that:

1. Is attributable to a mental or physical impairment, or a combination of mental and physical impairments, other than a sole diagnosis of mental illness;
2. Is manifested before the individual reaches 22 years of age;
3. Is likely to continue indefinitely;
4. Results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, or economic self-sufficiency; and
5. Reflects a need for a combination and sequence of special interdisciplinary or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated.

A child from birth to age nine, inclusive, who has a substantial developmental delay or specific congenital or acquired condition may be considered to have a developmental disability without meeting three or more of the criteria described in clauses (i) through (v) if the individual, without services and supports, has a high probability of meeting those criteria later in life.

There are many conditions that qualify as a DD including autism, brain injury (before age 22), cerebral palsy, other mental or neurological conditions (seizures), and intellectual disabilities which include Down syndrome, fetal alcohol spectrum disorder (FASD) and Fragile X syndrome. Other developmental disabilities may be strictly physical, such as blindness or deafness that began from birth or childhood.

1. 5.24 20 Targeted Case Management (State Plan Option) Targeted case management services are services furnished to assist individuals, eligible under the Medicaid State Plan. This can include:

• A person who has a DD Waiver
• A person with an ID on the waiting list for the DD Waiver who is eligible for Medicaid (in this instance the person may or may not have )
• A person with a DD on the waiting list for the DD Waiver who is eligible for Medicaid AND has a short-term special need (in this instance the person may or may not
• A person with an ID or DD not on the waiting list for the DD Waiver, who is eligible for Medicaid and targeted case management, but not DD Waiver (in this instance the person may or may not have have one of Virginia's other waivers) Monitoring/Follow Along Many CSBs or support coordination providers have protocols for how to provide support to people who do not receiving targeted case management. There may be different documentation and direct contact protocols for monitoring and follow-along.

Post Move Monitoring When a person in Southeastern Virginia Training Center is seeking to move to a more integrated home in the community, the SC plays an important role in ensuring a successful transition. The assessment and plan development process for a person discharging from the training center is similar to the process for someone already residing in the community. Additionally, there is supplemental funding available to ensure all identified essential supports are available and in place at the time of discharge. Virginia has approved limited funding as a part of the plan to support individuals transitioning from the training center or other state facility, according to the “community move process,” to a community home of their choice.

Transitional Funding, formerly known as “bridge funding,” can be used in a variety of ways to support these individuals as they move to their own homes or to a home licensed by DBHDS. The application is available on the DBHDS website. Please ask your supervisor for assistance with any additional funding resources available in your locality.

Choice of Support Coordinator Anyone seeking support coordination services must be offered a choice of SC. Choice of providers is always an option and can be exercised at any time by a person using SC services and documented on the Virginia Informed Choice Form at a minimum on an annual basis. Each provider of support coordination shall implement a written policy describing how people are assigned SCs and how they can request a change of their assigned SC or SC provider.

1. 5.24

have ) one of Virginia's other waivers one of Virginia's other waivers 21 Role of family and friends, the use of a Supported Decision-Making Agreement, Powers of Attorney, Authorized Representatives, Legal Guardians When working with someone, it should be presumed that they can tell everything about themselves, handle their own affairs, and make informed decisions about their goals and support needs to the same degree as someone who does not have a disability. In many instances, however, a person may want/need the input from others who know them well.

This can come from family or friends, who may choose to use a Supported Decision-Making Agreement, on an informal basis and/or from a conservator, authorized representative or legal guardian on a formal basis. No matter who is included in the process of getting to know someone, it is important to always remember that the person who uses services is at the center of all information gathering and planning. Each of these roles is discussed below.

Family & Friends A SC will encounter a wide variety of family. It is important to gain an understanding of what “family” means to the person being supported and who they consider a part of their family. A SC should ask for loved ones’ names and what they are called by the person. With permission, SCs should treat family members and friends as partners in getting to know the person and planning with them. Including and getting to know family members will go a long way to build trust.

Tips for including families:

• Start with the assumption that families want to make a positive contribution and have the best interests of their family member at heart.
• Resist characterizing families as “overprotective,” “not interested,” or “barriers to. . .”
• Engage families by asking for their side of the story. It may end up providing important information about history and ways to support their loved one.
• Recognize that often family members know the person best. They care about the person in a way that is different from everyone else and they will probably be involved in supporting their loved one for the rest of their lives.
• Appreciate the huge commitment, energy, and knowledge a family brings to the table.
• Make it a priority, as long as a person agrees, to sustain, value, and strengthen connections with family and friends. “Person-centered planning celebrates, relies on, and finds its sober hope in people’s interdependence. At its core, it is a vehicle for people to make worthwhile, and sometimes life changing, promises to one another.”
• John O’Brien

1. 5.24 22 Supported Decision-Making & Supported Decision-Making Agreements (SDMA) Everyone has the right to meaningfully participate in decisions regarding all aspects of life and everyone receives help with making decisions, not just people with disabilities. Many individuals with disabilities are able to live independent lives and make important decisions through the use of supported decision-making. Supported decision-making allows individuals with disabilities to maximize their self-determination by making the ultimate decision regarding their own lives, including supports and services, while receiving assistance of those they trust to ensure they receive all of the information needed to make an informed decision. It is important to practice supported decision-making starting at a young age, not just as an adult, for individuals to build their confidence with making decisions on their own.

Supported decision- making agreements (SDMAs) are the formal process of documenting who an individual wants to support them, in what areas of life, and how they want to be supported. Both the individual and the supporters consent to entering into this agreement. SDMAs can be updated and amended at any time. SDMAs are formally recognized in Virginia, as noted in §37.2-314.3. A SDMA is not a legal document a judge would order in court, but people should follow any choices the decision-maker makes, as the decision-maker has the right to make all final decisions.

A 2020 Supported Decision-Making Workgroup identified four principles for supported decision-making in Virginia.

That all individuals should be presumed capable of making their own decisions.

When an individual requires assistance in making decisions, the least restrictive option that meets the individual’s needs should be pursued, and every effort should be made to maximize an individual’s autonomy and independence.

Supporters, guardians, substitute decision-makers, and other agents should always take into consideration an individual’s expressed personal preferences to the extent appropriate.

Making good decisions takes practice and individual growth. Everyone should have the opportunity to learn and grow from making poor decisions, sometimes called “dignity of risk.” "Principal" means an adult with an intellectual or developmental disability who seeks to enter or has entered into a supported decision-making agreement with a supporter. "Supported decision-making agreement" means an agreement between a principal and a supporter that sets out the specific terms of support to be provided by the supporter, including (i) helping the principal monitor and manage his medical, financial, and other affairs; (ii) assisting the principal in accessing, obtaining, and understanding information relevant to decisions regarding his affairs; (iii) assisting the principal in understanding information, options, responsibilities, and consequences of decisions; and (iv) ascertaining the wishes and decisions of the principal regarding his affairs, assisting in communicating such wishes and decisions to other persons, and advocating to ensure the wishes and decisions of the principal are implemented. "Supporter" means a person who has entered into a supported decision-making agreement with a principal. (§ 37.2-314.3)

1. 5.24 23
2. Poor decision-making should not be motivation for restricting an individual’s rights through guardianship or substitute decision-making.

It is important for SCs know an individual communicates their preference or to ensure that someone who does is present when decisions are being made. If an individual has a SDMA, then SCs should request a copy of it and invite the Supporters to meetings as outlined in the SDMA. In instances when an individual has a substitute decision-maker, such as a legal guardian or authorized representative, efforts should be made to determine what the individual’s preferences or choice are and to follow them to the greatest extent possible.

Power of Attorney (POA) There are three types of power of attorney (POA): general POA, limited POA, and durable POA. “Power of Attorney” is defined as a writing or other record that grants authority to an agent to act in the place of the principal, whether or not the term power of attorney is used. "Principal" means an individual who grants authority to an agent in a power of attorney. (§ 64.2-1600)

1. 5.24 Decision-making supports are considered based on individual circumstances and least restrictive options are considered first. Someone with multiple, complex medical needs may benefit from more restrictive options due to a potential increase in the frequency and necessary timeliness of obtaining medical consent. 24 Authorized Representative (AR) It is important to note that an authorized representative (AR) acts on behalf of someone who lacks the capacity to make decisions about informed consent and participation in research. Lack of capacity is not something that can be decided by a SC, a family member, or even the person using support coordination services.

Legal Guardianship (LG) and Conservatorship In Virginia, one’s parent is considered to be a child’s legal guardian (LG) until the child reaches the age of 18.

Once a child reaches 18, a parent may petition the circuit court to become a LG for the child with DD if the parent feels the individual

is incapable of making life decisions. A person’s

LG

may

also

be

someone unrelated

to them. No matter whom the court appointed LG is, it is important as the SC to remember that:

• A legal guardian has to be appointed by the court.
• The LG

makes

decisions

that

are

pursuant to the guardianship court order

regarding

the

care

of

the

“incapacitated

person.” This

is

a

legal

term

and

is

only

used

here

because

it

is

such.

It

is

not

recommended

that

anyone

should

be referred

by

this

term

in

everyday

language.)

This

does

not

mean

that

the

voice

of

the

person themselves

should

not

be

heard.

In

fact,

it

is

incumbent

on

the

LG

to

encourage

participation

in

all decision

making

and

to

listen

to

the

individual

and

support

them

in

their

choices. "Guardian" means a person appointed by the court who is responsible for the personal affairs of an incapacitated person, including responsibility for making decisions regarding the person's support, care, health, safety, habilitation, education, therapeutic treatment, and, if not inconsistent with an order of involuntary admission, residence. (22VAC30-70-10) "Conservator" means a person appointed by the court who is responsible for managing the estate and financial affairs of an incapacitated person. (22VAC30-70-10) "Incapacitated person" means an adult who has been found by a court to be incapable of receiving and evaluating information effectively or responding to people, events, or environments to such an extent that the individual lacks the capacity to (i) meet the essential requirements for his health, care, safety, or therapeutic needs without the assistance or protection of a guardian or (ii) manage property or financial affairs or provide for his support or for the support of his legal dependents without the assistance or protection of a conservator. (22VAC30-70-10) "Authorized representative" means a person permitted by law or the human rights regulations to authorize the disclosure of information or to consent to treatment and services or participation in human research. The decision-making authority of an authorized representative recognized or designated under this chapter is limited to decisions pertaining to the designating provider. Legal guardians, attorneys-in-fact, or health care agents appointed pursuant to § 54.1-2983 of the Code of Virginia may have decision-making authority beyond such provider.

1. 5.24

25

• It is also the legal guardian’s responsibility to file annual reports with the local Department of Social Services (LDSS).

A conservator, also appointed by the circuit court, handles the financial affairs for someone. The LG and conservator may or may not be the same person.

The responsibilities of the conservator are to take care of and preserve the assets and income of the “incapacitated person” and to file annual reports with the commissioner of accounts regarding money and property received and disbursed.

Waiver Management System (WaMS) The Waiver Management System (WaMS) is a web-hosted data management system used to manage the DD Waivers. WaMS interfaces with the Medicaid Enterprise System (MES), establishes the assessment levels of care based on a person’s needs, and automates the service authorization process.

WaMS is customized to allow a single process for service authorizations for all three Waivers (Community Living, Family and Individual Supports, and Building Independence) supporting people with ID/DD. WaMS interfaces with various Electronic Health Record (EHR) systems to transfer data into WaMS.

SCs use WaMS for a variety of documentation requirements including the PC ISP, VIDES survey, authorizations for Waiver services, regional support team, and Waiver waiting list management Virginia Waiver Management System (WaMS) Portal. SCs should speak to their supervisors about getting their account set up. Once in WaMS, there are extensive user manuals, training videos, and tips.

Appeal Rights The Code of Federal Regulations at 42 CFR §431, Subpart E, and the Virginia Administrative Code (12VAC30-110-10 through 12VAC30-110-370), require that written notification be provided to individuals when DMAS or any of its contractors takes an action that affects the person’s receipt of services. This includes actions to deny a request for medical services or an action to reduce or terminate coverage after eligibility has been determined.

A SC may need to assist a person to request an eligibility appeal in writing within 30 days of receipt of the notice about the action. The individual may write a letter or complete an Appeal Request Form that would include:

• Name
• Medicaid ID number
• Phone number with area code, and

• a copy of the notice about the action Appeals are then mailed to:

1. 5.24 26 Appeals Division Department of Medical Assistance Services 600 E. Broad Street Richmond, Virginia 23219 Telephone: (804) 371-8488 Fax: (804) 452-5454 For reduction or termination of coverage, if the request is made before the effective date of the action and the action is subject to appeal, the coverage may continue pending the outcome of the appeal. However, the person may have to repay any services received during the continued coverage period if the agency’s action is upheld.

After the person files an appeal, they will be notified of the date, time, and location of the scheduled hearing. Most hearings can be done by telephone. The hearing officer’s decision is the final administrative decision rendered by DMAS. However, if the person disagrees with the hearing officer’s decision, an appeal may be filed at the local circuit court.

DMAS Appeal Rights page DMAS Appeals Form

1. 5.24 27 Centers for Medicare & Medicaid Services (CMS) Setting Regulations The Home and Community-Based Services (HCBS) settings regulations (previously known as the “final rule”) published in the Federal Register, became effective March 17, 2014. They were designed to enhance the quality of HCBS, provide additional protections, and ensure full access to the benefits of community living.

Settings regulations establish requirements for the qualities of settings for those who use Medicaid-reimbursable HCBS services.

HCBS Requirements for Residential/Non-residential Settings

• Supports full access to the greater community o Provide opportunities to seek employment, work in competitive integrated settings, engage in community life, control personal resources, and o Ensure that people use services in the community, to the same degree of access as those not using HCBS
• Selected by the person served from among setting options including non-disability specific settings and options for a private unit in a residential setting o Person-centered service plans document the options based on the person’s needs, preferences, and, for residential settings, resources available for room and board
• Ensures a person’s rights of privacy, dignity and respect, and freedom from coercion and restraint
• Optimizes one’s initiative, autonomy, and independence in making life choices, including, but not limited to, daily activities, physical environment, and with whom to interact
• Facilitates one’s choice regarding services and supports and who provides them Resource: Michelle ‘Shelli’ Reynolds, PhD UMKC Institute for Human Development CHAPTER 3: Qualifications

1. 5.24 28 For many of people, typical lives mean being surrounded by family and community and being an active member of the community (first circle in the diagram above). Sometimes, even with the best of intentions, services are put in place that create a barrier between people using those services and their family and community (middle circle). The goal should always be to organize services and supports around a person that reinforce the integration of services in a person’s life, family, and community (third circle above).

A residential setting that is provider-owned or controlled is subject to additional requirements. These settings include group homes, sponsored placements, and supported living situations.

HCBS Requirements for

Residential Settings

• Have a lease, or other signed legally enforceable agreement providing similar protections
• Have

access

to

privacy

in

their

sleeping

units

• Have

entrances

lockable

by

the

individual,

with

keys

provided

to

appropriate

staff

as

needed

• Have

a

choice

in

selecting

their

roommate(s)

if

they

share

a

room

• Have

the

freedom

to

decorate

and

furnish

their

sleeping

and/or

dwelling

unit

• Have

the

ability

to

control

their

daily

schedules

and

activities

and

have

access

to

food

at

any

time

• Be

able

to

have

visitors

at

any

time

• Be

able

to

physically

maneuver

within

the

setting

(e.g.,

setting

is

physically

accessible) To

learn

more

about

the

HCBS

settings

rule

go

to: https://www.medicaid.gov/medicaid/home-community-based-services/guidance/home-community-based-services-final-regulation/index.html Providers

may

ask

about

where

to

find

the

HCBS

Toolkit.

Information

can

be

found

at

this

link: https://www.dmas.virginia.gov/for-providers/long-term-care/waivers/home-and-community-based-services-toolkit/As

a

SC,

there

are

three

additional

regulations

to

be

aware

of.

They

are:

DD

Waiver

Regulations

–

The

three

DD

Waivers

–

Building

Independence

(BI),

Family

and

Individual

Supports

(FIS),

and

Community

Living

(CL)

share

the

same

set

of

regulations.

Service

authorization

and

operations

related

to

the

Waivers

fall

under

DBHDS.

Link: https://law.lis.virginia.gov/admincode/title12/agency30/chapter122/

DD

Waiver

Manual

–

The

Virginia

Medicaid

DD

Waivers

Provider

Manual

is

a

policy

manual

that

includes

the

DD

Waiver

regulations

and

expectations.

To

provide

a

better

understanding

of

the

Medicaid

Program,

this

manual

explains

Medicaid

rules,

regulations,

procedures,

and

reimbursement

and

contains

information

to

assist

the

provider

in

answering

inquiries

from

Medicaid

members.

Link:

1. 5.24 Though

it

is

not

the

responsibility

of

the

SC

to

(enforce)

provider's

adherence

to

the

additional

requirements,

it

is

within

their

responsibility

to

be

familiar

with

the

settings

requirements

as

they

may

need

to

discuss

the

regulations

with

individuals

they

support

and

their

families,

as

well

as

with

providers.

Support

Coordinators

should

consult

with

the

Community

Resource

Consultant

for

ongoing

or

repeated

issues

of

non-compliance

around

the

settings

regulations. 29 https://vamedicaid.dmas.virginia.gov/Office of Human Rights Regulations – The Office of Human Rights monitors compliance with the Human Rights Regulations by promoting the basic precepts of human dignity, managing the DBHDS Human Rights complaint resolution program, and advocating for the rights of persons with disabilities in our service delivery systems. Link: https://law.lis.virginia.gov/admincode/title12/agency35/chapter115/Office of Licensing Regulations – The Office of Licensing provides a license and oversight to providers who offer services to individuals who have a DD (and other categories). Services include case management and a multitude of other services. Link: https://law.lis.virginia.gov/admincode/title12/agency35/chapter105/Support Coordinator Qualifications SCs who provide DD SC and were hired after September 1, 2016 must possess a minimum of a bachelor's degree in a human services field or be a registered nurse (RN). SCs hired before September 1, 2016 who do not possess a minimum of a bachelor's degree in a human services field or are not a RN may continue to provide support coordination if they are employed by or contracting with an entity that had a Medicaid provider participation agreement to provide DD support coordination prior to February 1, 2005, and the SC has maintained employment with the provider without interruption, which must be documented in the personnel record.

SCs who provide ID targeted case management (ID TCM) may be hired: (i) Without a bachelor’s degree in a human services field but with one year of direct DD experience; or (ii) Without the five-year equivalency requirements recognized by the Office of Licensing, until one of these standards is met if a qualified supervisor has signed all assessments, individual support plans, and quarterlies completed by the SC. The names of any SC providing ID TCM under this return to the standard as written in the current regulation (now and as hired) should be emailed to CMSC@dbhds.virginia.gov so that DBHDS may maintain a record of CSB staff hired to only the level of the ID TCM standard.

Support Coordinator Required Training New SCs are required to complete 14 modules built on the principles of recovery, self- determination, person-centeredness, and community inclusion. The first 10 modules include a narrated and interactive PowerPoint, a PowerPoint test document, and links to information which may be downloaded and printed. DD SCs hired on or after April 1, 2019, are required to complete all modules and must demonstrate their knowledge and

1. 5.24 30 understanding of the content by passing a competency-based test for each module within 30 days of employment. The link for the first 10 modules is: Support Coordination/Case Management - Virginia Commonwealth University (vcu.edu).

Module 11 on Employment and 3 housing modules are in the Commonwealth of Virginia Learning Center. You must have an account to access these trainings. Login (virginia.gov).

The CSB performance contract requires all direct and contract staff that provide case management services to complete the case management curriculum developed by DBHDS and that all new staff complete it within 30 days of employment. DD case managers and SCs must complete the ISP training modules within 60 days or within 30 days of employment for new staff. You can access this training on the Commonwealth of Virginia’s Learning Center (COVLC): https://covlc.virginia.gov/Default.aspx

• PC ISP Training Development, Module 1 (Parts I and II)
• PC ISP Training Development, Module 2 (Parts III and IV)
• PC ISP Training Development, Module 3 (Part V) Background and List of Excluded Individuals and Entities (LEIE) Checks In order to comply with Federal Regulations and Virginia Medicaid policy, providers are required to ensure that Medicaid is not paying for any items or services furnished, ordered, or prescribed by excluded individuals or entities. Medicaid payments cannot be made for items or services furnished, ordered, or prescribed by an excluded physician or other authorized person when the individual or entity furnishing the services either knew or should have known about the exclusion. This provision applies even when the Medicaid payment itself is made to another provider, practitioner, or supplier that is not excluded, yet affiliated with an excluded provider.

A provider who employs or contracts with an excluded individual or entity for the provision of items or services reimbursable by Medicaid may be subject to overpayment liability as well as civil monetary penalties. All providers are required to take the following three steps to ensure federal and state program integrity:

1. Screen all new and existing employees and contractors to determine whether any of them have been excluded.
2. Search the HHS-OIG List of Excluded Individuals and Entities (LEIE) database monthly by name for employees, contractors, and/or entities to validate their eligibility for federal programs. See below for information on how to search the LEIE database.
3. Immediately report to DMAS any exclusion information discovered. Such information should be sent in writing and should include the individual or business name, provider identification number (if applicable), and what, if any, action has been taken to date. The information should be sent to: DMAS Attn: Program Integrity/Exclusions 600 E. Broad St, Ste 1300 Richmond, VA 23219 or E-mailed to: providerexclusions@dmas.virginia.gov.
4. 5.24 31 How to screen, assess and conduct an intake The community services board (CSB)/behavioral health authority (BHA) is the single point of entry for a person seeking services. The CSB/BHA will schedule an intake appointment with the individual. The individual should be asked to bring required documentation for the intake appointment. SCs should ask their supervisors for more information regarding the agency’s intake process.

The CSB/BHA shall provide anyone interested in accessing DD Waiver Services with a DBHDS provided resource guide that contains information including but not limited to case management eligibility and services, family supports- including the IFSP Funding Program, family and peer supports, and information on the My Life , My Community Website, information on how to access REACH services, and information on where to access general information.

Information gathered at intake (check with a supervisor for agency-specific requirements)

• Documentation to support diagnosis of DD (to include ID if applicable)
• Consent to exchange information
• Risk Awareness Tool (RAT)
• Human rights notification
• Documentation of choice between institution and community-based services
• Waitlist Documentation to support diagnosis of developmental disability (to include ID if applicable) Eligibility for Developmental Disability (DD) Waivers To be eligible for the DD Waiver a person must meet three criteria: diagnostic eligibility, functional eligibility, and financial eligibility.

Diagnostic Eligibility Diagnostic eligibility means that an individual must have a disability that affects the individual’s ability to live and work independently. The Diagnostic Eligibility Review Form can be used to ensure that collected documentation substantiates a diagnosis that confirms eligibility for SC services. A psychological or other evaluation of the individual may affirm that the individual meets the diagnostic criteria for developmental disability. SCs may want to use the optional Diagnostic Eligibility Review Form.

CHAPTER 4: Support Coordination: Assessment and Intake

1. 5.24 32 Financial Eligibility Financial eligibility means that the person seeking services meets the financial criteria to receive Medicaid.

This is determined by the LDSS, following the Medicaid eligibility rules used for people who need long-term care.

Functional Eligibility-Virginia Individual Developmental Disability Eligibility Survey (VIDES) To meet functional eligibility requirements, an individual must need the same support as someone who is living in an intermediate care facility (ICF) for people with an ID/DD. This is determined by the Virginia Individual DD Eligibility Survey (VIDES). There are different versions of this assessment depending on the age of the person seeking services.

• Infant VIDES - under the age of 3
• Children VIDES - between the ages of 3 through 17
• Adult VIDES - 18 and older Functional eligibility is established when someone meets the following established dependency level for the age-appropriate VIDES.
• Infant VIDES - must meet 2 out of the 5 categories
• Children VIDES - must meet 2 out of 8 categories
• Adult VIDES - must meet 3 out of 8 categories The VIDES should be completed in WaMS or in an electronic health record. Only an SC who has been trained may administer the VIDES. SCs should ask their supervisor for training.

Eligibility Summary An SC might determine that a person only meets one or two of the three eligibility criteria to receive a DD Waiver. For example, a person with an ID diagnosis may not meet the minimum functional criteria on the VIDES, rendering them ineligible to be placed on the DD Waiver waitlist. In this instance, the SC would provide that person with appeal rights and work with them to determine alternative options and resources that are available in the community.

Note: A person can be on the waitlist and not meet financial eligibility criteria.

Consent to Exchange Information The SC is responsible for ensuring there is documentation of consent to exchange information. During the initial assessment, as needed, and annually thereafter, the SC should ensure there are current consent forms for any collateral contacts or organizations to which the SC must communicate and/or release information pertaining to the person who uses SC services.

1. 5.24 33 Risk Awareness Tool The Risk Awareness Tool (RAT) was designed to increase awareness of the potential for a harmful event (i.e., bowel obstruction, fall with injury, etc.) to occur and to facilitate the process of taking action to reduce and prevent the risk. It assesses for potential risk in 11 key health and safety areas. The RAT is completed annually.

Human Rights Notification During the initial assessment and annually thereafter, the SC must ensure that the individual is aware of and has reviewed the human rights as described in the Regulations to Assure the Rights of Individuals Receiving Services from Providers Licensed, Funded, or Operated by the Department of Behavioral Health and Developmental Services (“Human Rights Regulations”). [12VAC35-115]. SC organizations are required to notify each individual and authorized representative about these rights and how to file a complaint. The notice shall be in writing and in any other form most easily understood by the person using services. The notice shall provide the name and phone number of the human rights advocate and give a short description of the human rights advocate's role.

The provider shall give this notice to and discuss it with the individual at the time services begin and every year thereafter. This notice shall be signed and filed in the individual’s services record.

More information regarding the Human Rights Regulations is located at https://dbhds.virginia.gov/quality-management/human-rights.

Determining Capacity According to the Human Rights Regulations (12VAC35-115-145. Determination of Capacity to Give Consent or Authorization), if the person receiving services is suspected of lacking the capacity to consent to treatment, services, or research, or to authorize the disclosure of information, the SC must obtain an evaluation conducted by or under the supervision of a licensed professional who is not directly involved with the individual to determine whether the individual has capacity to consent or to authorize the disclosure of information. See the specific requirements in 12VAC35-115-145.

Therefore, before an AR or LG is selected, a determination must be made by the above means that the person served is not capable of making informed decisions about care or consent to participate in research. This is true even if the person requests an AR or LG to be designated.

Choice of Waiver/Intermediate Care Facility During the initial assessment and while screening for the DD Waiver wait list, the SC is responsible for ensuring documentation that indicates the person’s desire for DD community-based care. This documentation ensures that the individual understands the choice between community-based care over institutional services. The required documentation is known as the Documentation of Recipient Choice Between Institutional Care or Home and Community-Based Services Form DMAS 459C. It is completed during the initial screening for the DD Waiver program and annually thereafter until the individual receives a DD Waiver. It should be maintained in the person’s record. Please see the next page for the Case Management and Wait List Eligibility Flowchart.

1. 5.24 34
2. 5.24 35 Supports Intensity Scale (SIS®) Supports Intensity Scale (SIS®) is an assessment tool that identifies the practical supports required by individuals to live successfully in their communities. DBHDS shall use the SIS Children's Version® (SIS-C®) for individuals five years through 15 years of age. DBHDS shall use the SIS Adult Version® (SIS-A®) for individuals 16 years of age and older.

SIS assessment requirements: a. At least every four years for those individuals who are 22 years of age and older. b. At least every three years for those individuals who are 16 years of age through 21 years of age. c. Every two years for individuals five years through 15 years of age when the individual is using a tiered service, such as group home residential, sponsored residential, supported living residential, group day, or community engagement. Another developmentally appropriate standardized living skills assessment approved by DBHDS, such as the Brigance Inventory, Vineland, or Choosing Outcomes and Accommodations for Children, shall be completed every two years for service planning purposes for those in this age grouping who do not receive a SIS assessment.

Once awarded a DD Waiver slot, the SIS process begins. DBHDS routinely communicates to SIS vendors the order for SIS assessment completion. To move forward with scheduling, the SIS vendors rely on SCs for needed information. The SC is responsible for identifying qualified respondents and dates the SC is available to participate in the SIS assessment.

For individuals who desire additional information about the SIS, The AAIDD, the copyright holder and sole owner of the Supports Intensity Scale AAIDD, has developed information for respondents who have questions.

The aim is to explain what to expect during the interview, the SIS Family Friendly Report, and provide a SIS Respondent Handbook.

SIS-A Respondent Resources: https://www.aaidd.org/sis/sis-a/sis-a-resources SIS-C Respondent Resources: https://www.aaidd.org/sis/sis-c/sis-c-resources A completed SIS Family Friendly Report is made available to the board's SIS point person via SIS Online. The SC is responsible for sharing a copy of the SIS report with all providers and family members. Team members should use the SIS in conjunction with Virginia Supplemental Questions, the person-centered planning process, and other assessment information to develop an individual's ISP.

A mathematical algorithm uses the SIS scores to assign one of seven levels of need and one of four reimbursement tiers to each SIS assessment. The reimbursement tier sets the reimbursement rate for tiered DD waiver services (group home, sponsored residential, supported living, independent living supports, group day, community engagement, and group supported employment). This process provides greater reimbursement for smaller settings and for supporting those with more intensive needs. For more information on the SIS and the SC's role in the assessment, review the forms at the end of this handbook.

1. 5.24 36 Physical Exam When a person receives a DD Waiver slot, the SC should request documentation of a recent physical examination and document the date in WaMS. It is expected that people will make a good faith effort to obtain a physical on a regular basis and as needed. The physical exam must have been completed no more than 12 months prior to the initiation of DD Waiver services. For children through 21 years of age, physicals must be completed according to the EPSDT frequency.

DMAS 460 Virginia Informed Choice Form (DMAS 460) When working with an individual to determine choice of providers, it is crucial for the SC to ensure the person is aware of all options. The person should be given information on all available DD Waiver services and SCs.

Many CSBs keep an up-to-date list of local DD Waiver providers. Additionally, the SC could direct the individual and family to the DMAS provider search tool. A signed copy must be retained in the person’s electronic medical record. The Virginia Informed Choice Form (DMAS 460) should be reviewed and completed with the person and/or substitute decision-maker at enrollment into the DD Waiver, updated annually (and include choice and name of SC), when there is a request for a change in waiver providers, when new services are requested, or when the person wants to move to a new location or is dissatisfied with the current provider.

DMAS 225 Medicaid Long Term Care (LTC) Communication Form The DMAS 225 is a form that serves as a method of communication between the SC and the LDSS. The DMAS 225 is required in the following circumstances:

• Home and community-based waiver services are implemented
• An individual dies, with a description of the cause of death along with documentation
• An individual is discharged or terminated from ALL waiver services
• Any other circumstances (including hospitalization) that cause home and community-based waiver services to cease or be interrupted for more than 30 calendar days
• A selection by the individual or his family/caregiver, as appropriate, of a different support coordination/case management provider Prompt submission of this form is necessary to ensure that LDSS has correct and current information in order to determine patient pay responsibilities and ensure ongoing eligibility for Medicaid. For more detailed information about the SC’s role as it pertains to patient pay, see the link below. More information about patient pay can be found in Chapter 6 patient pay.

1. 5.24 37

CHAPTER 5: Wait List and Slot Assignment Wait List In Virginia, the need for DD Waiver services is greater than the number of slots Virginia has available to distribute. Therefore, everyone who meets eligibility criteria and requests DD Waiver services is added to a waitlist. Because DD waiver slots are distributed based on urgency of need and the number of waiver slots are made available based on Virginia’s budget, there is no way to tell how long a person will remain on the waitlist.

Key point to remember: When placing someone on the waitlist, the Support Coordinator should ensure the family knows what services they would utilize if offered a waiver slot. The SC should regularly monitor the needs of people and discuss the services that are available under the DD Waiver. Remember that a person must be willing to use services within 30 days of being awarded a slot. There is, however, a method for determining the urgency of need among those waiting for services.

Support Coordination while on the Waitlist If the individual is Medicaid eligible, and is determined to meet either DD or ID active support coordination/case management service criteria, and the individual is requesting support coordination/case management services, the SC may open the individual to Medicaid targeted case management services according to the following parameters:

• When an individual with ID meets Medicaid targeted case management criteria, an ISP, in compliance with DBHDS regulations, is developed to address the service need(s). SCs may engage in a monthly allowable activities/contacts and face-to-face contacts at least every 90 calendar days (plus a 10-day grace period) to address the service need(s) identified in the ISP.
• Individuals with DD, other than ID, may not receive routine, ongoing support coordination/case management services unless there is a documented “special service need”. CSBs cannot bill for individuals on the DD waiver waitlist receiving DD (non-ID) support coordination/case management services unless a special service need is identified.

If a special service need is identified for an individual on the DD waiver waiting list, an ISP must be developed to address that need. A special service need is one that requires linkage to and temporary monitoring of those supports and services identified in the ISP to address an individual's mental health, behavioral, and medical needs or provides assistance related to an acute need that coincides with support coordination allowable activities (see below). SCs must make face-to-face contact with the individual at least every 90 calendar days to monitor the special service need, and documentation is required to support such contact. If an activity related to the special service need is provided in a given month, then the SC would be eligible for reimbursement. Once the special service need is addressed related to the specific activity identified, billing for the service may not continue until a special service need presents again.

1. 5.24 38

• The priority screening should be reviewed anytime there is a change in circumstance to assure it accurately reflects the support needs of the person seeking services.
• Only those who meet Priority One status can be assigned an available DD Waiver slot.
• Those assigned with a Priority two or Priority three status cannot be awarded a CL Waiver or FIS waiver unless every person in the state who is assigned a Priority One status, already has a slot.
• For assignment of the BI waiver, a person assigned to Priority Two or Three may receive a BI slot if no one in a higher priority category is requesting and qualifies for assignment of the BI waiver.

Key Points to Remember: Examples of special service needs for people with DD who are waiting for waiver services could include:

• A child with autism on the waiting list needs to access behavioral services;
• An adult experiences the loss of a family caregiver and needs to look for alternate housing;
• Following a stroke an adult needs to locate specialized medical services to transition back home;
• A family member reports a child on the waiting list has experienced changes in his health status and needs to explore options to avoid placement in an institutional setting;
• A young person is transitioning out of school and needs to access vocational rehabilitation or employment services;
• A young woman who has limited contact with family begins experiencing seizures and needs to support to locate a neurologist;
• New neighbors move into a person's neighborhood resulting in escalating conflict between the person with DD and the neighbors.

Individuals with no identified funding source are provided with emergency services and, subject to the availability of funds appropriated for them, case management services. The SC assists individuals who are not admitted to support coordination/case management services to identify other appropriate and available services. Individuals on the DD Waiver waitlist are provided with information about the Individual and Family Support Program (IFSP) and other services for which they may be eligible.

Depending on the availability of state and local resources, individuals may be offered other CSB-funded services. In collaboration with DBHDS, the CSB monitors all individuals on the DD Waiver waitlist and provides CSB contact information should the individual’s status change and a reassessment of needs is indicated.

Priority Needs Checklist The Priority Needs Checklist must be completed and submitted in order to add a person to the waitlist. The checklist identifies the reason a person falls into priority category (one, two, or three) and is completed after the VIDES has been conducted. The Priority Needs Checklist is located and completed in WaMS under the screening and assessments section. Priority status is based on how much and how urgently someone is in need of help.

Critical Needs Summary

The SC must also complete a Critical Needs Summary (CNS) in WaMS for those designated as having a Priority One status. The purpose of the CNS is to determine a person’s level of urgency. This is a required step in placing a person on the waitlist. In WaMS, the CNS option will appear under the screening and assessments section after the Priority Needs Checklist has been completed and submitted.

1. 5.24 Right to Appeal Once a person has been placed on the DD Waiver waitlist, the SC must send a letter notifying them of appeal rights. Additionally, if a person on the waitlist has a change in priority status, they must also be issued appeal rights if moving to a lower priority.

Annual Waitlist Contact Additionally, once a year DBHDS will send a letter to everyone on the DD Waiver waitlist. Included in the letter will be instructions to review and sign the Documentation of Individual Choice Between Institutional Care or Home and Community-Based Services Form and the Needed Services Form. If the

DD

Waiver Slot Allocation General Information DD Waiver slots become vacant when someone who was previously using DD Waiver services moves out of state, passes away, moves into a nursing facility or institution, no longer meets eligibility criteria, or chooses to no longer utilize the supports provided under the DD Waiver. Currently the number of slots is limited by the availability of funding for DD Waiver services. Funds are managed at the state level and the appropriation of additional funds to increase the number of slots is dependent upon Virginia General Assembly action. Each CSB is allotted a designated number of slots. If an assigned slot becomes vacant, the CSB must use it in a timely manner to provide DD Waiver services to another eligible individual. Slots are reassigned to people on the DD Waiver waitlist by the waiver slot assignment committee (WSAC).

When the General Assembly allocates more than 40 slots for a given waiver, allocations will be made by providing one slot per board then a standard calculation (considering priority numbers per board) will be used

to

disseminate

the

remaining

slots.

When the General Assembly allocates less than 40 slots for a given waiver, allocations will be made by combining all WSACs within a region. Each WSAC will be represented by the assigned facilitator and two additional representatives per committee.

Waiver Slot Assignment Committee WSACs were developed to establish a means for determining the assignment of DD Waiver slots. The DD Waiver separates the eligibility determining entity (CSB SCs) from the entity who determines slot assignment. There is a WSAC in each locality/region of Virginia. The committee is comprised of people with diverse personal and professional backgrounds, as well as varied knowledge and expertise and no identified conflict of interest. For more information on qualifications for committee members and the responsibilities of the WSAC members, please refer to the WSAC forms at the end of this handbook. SCs play an important role in the assignment of a vacant DD Waiver slot. They must ensure that information in WaMS accurately reflects an individual’s current needs. When a slot is available for assignment, the CSB contacts the regional support specialist (RSS) and a WSAC meeting is convened. For more information SC’s role in the operations of WSAC, please refer to the WSAC forms at the end of this handbook.

1. 5.24 39 forms

are

not

completed

in

the

WaMS

portal

or

received

back

within

30

days,

DBHDS

will

attempt

a

second

mailing

of

the

forms,

plus

the

Notice of Action letter informing the individual that he/she will be removed from the waiting list

if

the

second

set

of

forms

are

not

completed

in

the

WaMS

portal

or

received

within

60

days.

At

the

end

of

the

60

days,

if

no

forms

are

received

or

appeal

filed,

the

individual’ s

name

will

be

removed

from

the

waiting

list.

Quarterly,

CSBs

will

receive

completed

Choice

forms

for

individuals

on

their

portion

of

the

waiting

list

for

inclusion

in

their

files

and

a

report

of

the

names

of

individuals

whose

names

have

been

removed

from

the

waiting

list. 40

• Individual’s profile (demographics, contact information, diagnosis etc.)
• Current/updated VIDES Slot Assignment Once a person is offered a DD Waiver slot, the SC is responsible for ensuring that the transition to Waiver services includes a thorough review of the assessment information and service options under the DD waiver.

Those responsibilities are listed below.

Waiver Slot Management In addition to updating the assessments and obtaining documentation of informed choice, the SC is also responsible for enrolling the person into the newly assigned slot. When a slot has been assigned, the enrollment status of the person in WaMS is listed as projected enrollment status. In order to initiate services, the person’s status must be moved to active status. This process is completed in WaMS. See the WaMS CSB user guide section 9 for more detailed instructions of how to move a person from projected to active status.

Retain a Slot At times, the services for a person are delayed in starting or may be interrupted for some reason such as a hospitalization or difficulty in locating a service provider. In this instance, if services are interrupted or delayed for 30 days, the CSB must request that the DD Waiver slot be held for that person. The SC will then complete the retain slot form located in WaMS. More detailed instructions on how to complete a retain slot form can be found in section 10 of the WaMS CSB user guide.

Emergency Slot At times, an SC may provide support to someone who needs immediate access to DD waiver services. There is a specific criterion that the person must meet in order for a SC to request access to an dmergency DD Waiver slot.

After exploring all possible alternative options, a CSB can request access to an emergency Waiver slot by submitting an emergency slot request form.

Reserve Slot Request Form At times, a SC may be providing support to someone who has experienced a change in assessed needs, requiring services available in a different waiver. The reserve slots enable a safety net with which someone can return to the original waiver, if needed. The SC must ensure that the person meets the criteria in order to request a reserve DD Waiver slot. There is a chronological waitlist that DBHDS keeps for reserve slots funded by the General Assembly action.

Update WaMS Data In order for DD Waiver services to be initiated, the SC should ensure that any information in WaMS is accurate and up to date, including but not limited to:

1. 5.24 41 Introduction Virginia’s Medicaid Waivers, which are referred to as Home and Community-Based Services (HCBS), can cover supports a person needs to live independently at home and in the community by combining federal and state money to provide long-term community-based supports for people who are elderly or have disabilities.

Waivers enable Virginia to offer a variety of standard medical and non-medical services without the requirement that someone live in an institution in order to use those same services. This handbook focuses on the DD Waivers. Medicaid Waivers expand Medicaid eligibility to those who may not otherwise qualify for services based on Medicaid financial requirements. Medicaid Waivers provide an opportunity for people to transition from institutions and large settings to community-based settings. As a result, Waivers allow people to be active in and live in their own community, connect with people without disabilities, and have greater independence and flexibility in their lives.

The state agency that administers the DD Waivers in Virginia is DMAS. DBHDS manages day-to-day DD Waiver operations. Locally, DD Waiver services are coordinated by CSBs/BHAs. Support coordination services are provided by SCs employed by CSBs/BHAs and private providers under contract with the CSBs/BHAs across the state.

Brief History of Developmental Disability Waivers HCBS Waivers were established by the U.S. Congress in 1981 to slow the growth of Medicaid spending for nursing facility care and to address criticism of Medicaid’s institutional bias. Congress was responding to the growth in institutional costs and to people with disabilities who preferred to live in their own homes with services such as personal care and community living supports. States were given the option to develop waiver programs as alternative services for people who are eligible for placement in an institution.

Virginia first applied for a waiver for those with an intellectual disability in 1990, with the federal Medicaid agency, the Center for Medicare and Medicaid Services (CMS). In early 1991, Virginia’s waiver CHAPTER 6: Developmental Disability Waiver & Services

1. 5.24 42 application was accepted by CMS, and Virginia was able to begin offering services through what was then called the Mental Retardation Waiver. This waiver, which was renamed the ID Waiver, was amended several times over the next 20 years, increasing the scope of community support services.

In 2000, the individual and family DD support Waiver was established to serve people with DD not meeting the diagnostic criteria for the ID Waiver. In 2005, Virginia began the day support Waiver, which focused on day support and employment activities, allowing for additional people to be supported while waiting to use more comprehensive services offered through the ID Waiver.

Description of Developmental Disability Waivers The DD Waivers provide supports and service options for successful living, learning, physical and behavioral health, employment, recreation, and community inclusion.

The DD Waivers are designed to serve individuals of any age with a DD and children (birth through age 9) with a substantial developmental delay or specific congenital or acquired condition. There are three DD Waivers, the building independence waiver, the family and individual supports waiver and the community living waiver.

• The building independence waiver (BI) is for adults (18+) who are able to live independently in the community. Individuals own, lease, or control their own living arrangements and supports are complemented by non-waiver-funded rent subsidies. BI Services at a glance
• The family and individual supports waiver (FIS) is for individuals living with their families or friends, in their own homes, or in supported living (for those over 18) including supports for those with some medical or behavioral needs. This is available to both children and adults. FIS Services at a glance
• The community living waiver (CL) includes residential supports and a full array of medical, behavioral, and non-medical supports. This is available to adults and children and may include 24/7 supports for individuals with complex medical and/or behavioral support needs through licensed services. CL Services at a glance Services in Waivers The services available under the DD Waivers are listed below in alphabetical order. This listing provides the most current information available. DMAS also has a DD Waiver policy manual located here. The Compatible/Incompatible Combinations of services in the DD Waivers chart can be accessed in Chapter 15 under Waiver.

Assistive Technology Service Description: Assistive technology is specialized medical equipment, supplies, devices, controls, and appliances, not available under the State Plan for Medical Assistance, which enable individuals to increase their abilities to perform activities of daily living (ADLs), or to perceive, control, or communicate with the

1. 5.24 43 environment in which they live, or which are necessary for life support, including the ancillary supplies and equipment necessary to the proper functioning of such technology.

In order to qualify for these services, the individual shall have a demonstrated need for equipment or modification for remedial or direct medical benefit primarily in the individual's home, vehicle, community activity setting, or day program to specifically improve the individual's personal functioning. Assistive technology shall be covered in the least expensive, most cost-effective manner. Equipment or supplies already covered by the State Plan may not be purchased under the waiver. The SC is required to ascertain whether an item is covered through the State Plan before requesting it through the waiver.

Service Units and Service Limitations: Maximum $5000 per calendar year.

Benefits Planning Services Service Description: Benefits planning is an individualized analysis and consultation service. This service assists recipients of a DD waiver and social security (supplemental security income, social security disability insurance) to understand their personal benefits and explore their options regarding working, how to begin employment, and the impact employment will have on their state and federal benefits. This service includes education and analysis about current benefits’ status and implementation and management of state and federal work incentives as appropriate. Benefits planning involves the development of written resource materials, which aid individuals and their families/legal representatives in understanding current and future rewards that come from working, thereby reducing uncertainties associated with losing necessary supports and benefits if they choose to work or stay on the job. This service facilitates individuals in making informed choices concerning the initiation of work. Furthermore, it provides information and education to individuals currently employed in making successful transition to financial independence.

Allowable activities include but are not limited to: Pre-employment benefits review which may include: a. Benefits planning query (BPQY from Social Security Administration (SSA) b. Pre-employment benefits summary and analysis (BS&A) c. Employment change benefits summary and analysis Work incentives development or revisions (PASS, IRWE, BWE, IDA): a. Plan to achieve self-support (PASS) b. Impairment-related work expenses (IRWE) c. Blind work expenses (BWE) d. Individual development accounts (IDA) e. Student earned income exclusion (SEIE) f.

Medicaid while working g. Medicaid Works (Virginia’s Medicaid Buy-In Program) h. Work incentive revisions

1. 5.24 44 Resolution of SSA benefits issues: a. Overpayments b. Subsidies c. Work activity reports Other Services: a. ABLE now b. Financial health assessment Service units and service limitations: The annual year limit for benefits planning services is $3,000. No unspent funds from one plan year may be accumulated and carried over to subsequent plan years. Providers may not bill for waiver benefits planning services while the eligible individual has an open employment services case with the Department for Aging and Rehabilitative Services (DARS) and is eligible for the same service through DARS.

Center-Based Crisis Supports Service description: Center-based crisis supports provide long term crisis prevention and stabilization in a residential setting (crisis therapeutic home) through utilization of assessments, close monitoring, and a therapeutic milieu. Services are provided through planned and emergency admissions. Planned admissions will be provided to individuals who are receiving ongoing crisis services and need temporary, therapeutic interventions outside of their home setting in order to maintain stability. Crisis stabilization admissions will be provided to individuals who are experiencing an identified behavioral health need and/or a behavioral challenge that is preventing them from experiencing stability within their home setting.

Allowable activities include but are not limited to:

1. Psychiatric, neuropsychiatry, and psychological assessment, and other assessments and stabilization techniques
2. Medication management and monitoring
3. Behavior assessment and positive behavior support
4. Intensive care coordination with other agencies and providers to assist the planning and delivery of services and supports to maintain community placement of the individual
5. Training of family members and other caregivers and service providers in positive behavioral supports to maintain the individual in the community and
6. Assistance with skill-building as related to the behavior creating the crisis in areas such as self-care/ADLs, independent living skills, self-esteem building activities, appropriate self-expression, coping skills, and medication compliance.

Service units and service limitations: 1 day unit up to 6 months in 30 day increments.

Community-Based Crisis Supports Service description: Community-based crisis supports are ongoing supports to individuals who may have a history of multiple psychiatric hospitalizations; frequent medication changes; enhanced staffing required due

1. 5.24 45 to mental health or behavioral concerns; and/or frequent setting changes. Supports are provided in the individual’s home and community setting. Crisis staff work directly with and assist the individual and their current support provider or family. Techniques and strategies are provided via coaching, teaching, modeling, role-playing, problem solving, or direct assistance. These services provide temporary intensive services and supports that avert emergency psychiatric hospitalization or institutional placement or prevent other out-of-home placement.

Allowable activities include but are not limited to:

1. Psychiatric, neuropsychiatric, and psychological assessment, and other assessments and stabilization techniques
2. Medication management and monitoring
3. Behavior assessment and positive behavior support
4. Intensive care coordination with other agencies and providers to assist the planning and delivery of services and supports to maintain community placement of the individual
5. Training of family members and other caregivers and service providers in positive behavioral supports to maintain the individual in the community
6. Assisting with skill building as related to the behavior creating the crisis in areas such as self-care/ADLs, independent living skills, self-esteem building activities, appropriate self-expression, coping skills, and medication compliance Service units and service limitations: 1 day unit up to 6 months in monthly increments.

Community Coaching Service Description: Community coaching is a service designed to assist people in acquiring a specific skill or set of skills to address a particular barrier(s) preventing a person from participating in activities of community engagement.

Allowable activities include but not limited to: (determined with age sensitivity in mind and reflective of the person’s interests): Skill building through participation in community activities and opportunities such as outlined in Community Engagement and encompassing:

• Activities and events in the community, volunteering, etc.
• Community, educational or cultural activities and events
• Skill-building and support in building positive relationships
• Routine needs while in the community
• Supports with self-management, eating, and personal needs of the individual while in the community
• Assuring safety Community coaching requires 1:1 support and must take place solely in community settings.

1. 5.24 46 Service units and service limitations 1 hour unit, up to 66 hours/week alone or in combination with other day options Community Engagement Service description: Community engagement supports and fosters the ability of a person to acquire, retain, or improve skills necessary to build positive social behavior, interpersonal competence, greater independence, employability, and personal choice necessary to access typical activities and functions of community life such as those chosen by the general population. These may include community education or training, retirement, and volunteer activities.

Community engagement provides a wide variety of opportunities to facilitate and build relationships and natural supports in the community, while utilizing the community as a learning environment. These activities are conducted at naturally occurring times and in a variety of natural settings in which the individual actively interacts with persons without disabilities (other than those paid to support the individual). The activities enhance involvement with the community and facilitate the development of natural supports.

Allowable Activities: Skill building, education, support and monitoring that assists with the acquisition and retention of skills in the following areas:

• Activities and public events in the community
• Community educational activities and events
• Interests and activities that encourage meaningful use of leisure time (e.g., through participating in sports/exercise, a club or other social group, a class to learn a new hobby)
• Unpaid work experiences (i.e., volunteer opportunities)
• Maintaining contact with family and friends Skill-building and education in self-direction designed to enable achievement in one or more of the following outcomes particularly through community collaborations and social connections developed by the program ( e.g., partnerships with community entities such as senior centers, arts councils, etc.).

Community engagement must be provided in the least restrictive and most integrated settings according to the individual’s person-entered plan and individual choice.

Service units and service limitations: 1 hour unit, up to 66 hours alone or in combination with other day options; no more than a ratio of 1:3 and must take place solely in the community.

Community Guide Service description: Community guide services include direct assistance to promote individuals’ self-determination through brokering community resources that lead to connection to and independent participation in integrated, independent housing or community activities so as to avoid isolation. This means that community guides investigate and coordinate as necessary the available naturally occurring community resources to facilitate the individual’s participation in those resources of interest to the individual.

7.5.24 47 Allowable Activities: This service may be provided by persons with one of two emphases:

• General community guide involves using existing assessment information regarding the individual’s general interests to determine specific preferred activities and venues that are available in the individual’s community to which the individual desires to be connected to promote inclusion and independent participation in the life of the individual’s community. o Use assessment and other information provided by the SC along with an in-depth discussion and with the individual and people who know the individual o Assist the individual in connecting to the identified community resources o Provide advocacy and informational counseling o Escort to or demonstrate means of accessing identified integrated community activities, supports, services, or resources o Follow up with individual to determine and document the individual’s participation
• Community housing guide involves supporting an individual’s move to independent housing by helping with transition and tenancy sustaining activities. o Complete tenant screening o Develop a plan using the community housing guide roadmap form o Assist with the housing search and application process o Help identify and request resources to cover expenses o Assist in arranging for and supporting details of the move o Provide education and training on the role, rights, and responsibilities of the tenant and landlord o Provide training in being a good tenant and lease compliance o Assist in resolving disputes with landlords or neighbors o Assist with the housing recertification process Community guide is expected to be a short, periodically intermittent, intense service associated with a specific outcome. An individual may receive one or more of the two types of community guide services in a plan year.

Community guide activities conducted not in the presence of the individual shall not comprise more than 25 percent of the authorized plan for support hours. The community guide shall not supplant, replace, or duplicate activities that are required to be provided by the SC. Prior to accessing funding for community guide, all other available and appropriate funding sources shall be explored and exhausted.

Service units and service limitations: Each type of community guide service may be authorized for up to six consecutive months, and the cumulative total across both may be more no more than 120 hours in a plan year.

1. 5.24 48 Companion Services Service description: Companion services provide nonmedical care, socialization, or support to adults ages 18 and older. This service is provided in an individual's home or at various locations in the community.

Allowable activities include, but are not limited to:

1. assistance or support with tasks such as meal preparation, laundry, and shopping;
2. assistance with light housekeeping tasks;
3. assistance with self-administration of medication;
4. assistance or support with community access and recreational activities; and
5. support to assure the safety of the individual.

Unlike personal assistance and residential support, companion services do not permit routine support with activities of daily living (such as using the bathroom, bathing, dressing, or grooming). The allowable activities center on “instrumental activities of daily living” (meal prep, shopping, community integration, etc.).

Companion services may be self-directed or agency-directed.

Service units and service limitations: 1 hour unit consumer-directed or agency-directed up to 8 hours a day, 18 and older.

Consumer Directed Services Facilitation Service description: Consumer-directed services facilitation uses the support of a services facilitator who is a Medicaid-enrolled provider. A services facilitator can be enrolled as an independent Medicaid provider or as an employee of a Medicaid-enrolled services facilitation agency provider. The services facilitator supports eligible individuals, and sometimes their families, in properly using consumer-directed services (CD services).

CD services empower the person with a disability to have greater control over the services they use. They can assess their own needs, determine how and by whom these needs should be met, and monitor the quality of services they use. CD services may be used in differing degrees and may span different types of services.They range from independently making all decisions and managing services directly, to using a representative to manage needed services. The underlying principle of CD services is that people with disabilities have the primary authority to make choices that work best for them, regardless of the nature or extent of their disability or the source of payment for services.

Service units and service limitations: Per visit, initial and 6-month re-assessments. The online training is found on the Partnership for People with Disabilities website.

1. 5.24 49 Crisis Support Services Service description: Crisis support services are intensive supports provided by appropriately trained staff in the areas of crisis prevention, crisis intervention, and crisis stabilization to a person who may experience an episodic behavioral or psychiatric crisis in the community which has the potential to jeopardize his current community living situation. This service shall be designed to stabilize a person and strengthen his current living situation so they can be supported in the community during and beyond the crisis period.

This service includes: crisis prevention, crisis intervention, and crisis stabilization

• Crisis prevention services provide ongoing assessment of medical, cognitive, and behavioral status as well as predictors of self-injurious, disruptive, or destructive behaviors, with the initiation of positive behavior supports to prevent occurrence of crisis situations. Crisis prevention also encompasses providing support to the family and the individual through facilitating team meetings, revising the plan, etc. as they implement changes to the plan for support and address any residual concerns from the crisis situation. Staff will arrange to train and mentor staff or family members who will support the individual long term once the crisis has stabilized in order to minimize or prevent recurrence of the crisis. Crisis support staff will deliver such support in a way that maintains the individual's typical routine to the maximum extent possible.
• Crisis intervention services are used in the midst of the crisis to prevent the further escalation of the situation and to maintain the immediate personal safety of those involved. Crisis intervention is a relatively short-term service that provides a highly structured intervention that may include temporary changes to the person’s residence, removal of certain items from the setting, changes to the person’s daily routine and emergency referrals to other care providers.

Those providing crisis intervention services must also be well-versed and fluent in verbal de-escalation techniques, including active listening, reflective listening, validation, and suggestions for immediate changes to the situation.

• Crisis stabilization services begin once the acuity of the situation has resolved and there is no longer an immediate threat to the health and safety of those involved. Crisis stabilization services are geared toward gaining a full understanding of all the factors that precipitated the crisis and may have maintained it until trained staff from outside the immediate situation arrived. Crisis stabilization plans are developed by staff trained in basic behavioral treatment and crisis management. These plans may include modifications to the environment, interventions to enhance communication skills, or changes to the individual’s daily routine or structure. Staff developing these plans must be able to train support staff, family, and other significant persons in the individual’s life.

Service units and service limitations: 1 day unit; limits vary by component.

1. 5.24 50 Electronic Home-Based Services Service description: Electronic home-based services are goods and services based on Smart Home© technology. This includes purchases of electronic devices, software, services, and supplies not otherwise provided through the waiver or through the State Plan that would allow access to technology that can be used in a person’s residence to support greater independence and self-determination.

The items and services must:

• Decrease the need for other Medicaid services (e.g., reliance on staff supports); and/or
• promote inclusion in the community; and/or
• increase the individual’s safety in the home environment.

Allowable activities include:

• Assessment for determining appropriate equipment/devices
• Acquisition, training, and use of goods and services
• Ongoing maintenance and monitoring services to address an identified need in the individual’s person-centered service plan (including improving and maintaining the individual’s opportunities for full participation in the community).

Service units and service limitations: Up to $5,000 annually. Not available to individuals using residential supports that are reimbursed on a daily basis (e.g., group home, sponsored or supported living residential services).

Employment and Community Transportation Service description: Employment and community transportation is offered in order to enable individuals to gain access to waiver and other community services or events, activities, and resources, inclusive of transportation to employment or volunteer sites, homes of family or friends, civic organizations or social clubs, public meetings or other civic activities, and spiritual activities or events as specified by the service plan and when no other means of access is available. This service is offered in addition to medical transportation required under 42 CFR §431.53 and transportation services under the State Plan.

Environmental Modifications Service description: Environmental modifications are physical adaptations to the individual's primary home or primary vehicle that are necessary to ensure the health and welfare of the individual or that enable the individual to function with greater independence. Such adaptations may include, but shall not necessarily be limited to, the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies that are necessary for the individual. Modifications may be made to a primary automotive vehicle in which the individual is transported if it is owned by the individual, a family member with

1. 5.24 51 whom the individual lives or has consistent and ongoing contact, or a nonrelative who provides primary long-term support to the individual and is not a paid provider of services.

Service units and service limitations: Up to $5,000 calendar year.

Waiver will not pay for durable medical equipment.

Group Day Services Service description: Group day services include skill-building or supports for the acquisition, retention, or improvement of self-help, socialization, community integration, employability and adaptive skills. They provide opportunities for peer interactions, community integration, and enhancement of social networks.

Supports may be provided to ensure an individual’s health and safety.

Skill-building is a required component of this service unless the individual has a documented degenerative condition, in which case day support may focus on maintaining skills and functioning and preventing or slowing regression rather than acquiring new skills or improving existing skills.

Group day services should be coordinated with any physical, occupational, or speech/language therapies listed in the person-centered plan.

Allowable activities include but are not limited to skill development and support in order to:

• Develop self, social, and environmental awareness skills
• Develop positive behavior, using community resources
• Volunteer and connect with others in the community
• Engage in career planning to include establishing a career goal
• Develop skills required for paid employment in a community setting Service units and service limitations: 1 hour unit up to 66 hours/week alone or in combination with other day options; Maximum 1:7 ratio.

Group Home Residential Service description: Group home residential consists of skill-building, routine supports, general supports, and safety supports, provided primarily in a licensed or approved residence that enable an individual to acquire, retain, or improve the self-help, socialization, and adaptive skills necessary to reside successfully in home and community-based settings.

Group home residential services may be in the form of continuous (up to 24 hours per day) services performed by paid staff who shall be physically present in the home. These supports may be provided individually or simultaneously to more than one individual living in that home, depending on the required support. These supports are typically provided to an individual living (i) in a group home or (ii) in the home of an adult foster care provider.

1. 5.24 52 This service includes the expectation of the presence of a skills development (formerly called training) component, along with the provision of supports, as needed.

Group home residential services shall be authorized for Medicaid reimbursement in the Person-Centered Plan only when the individual requires these services and when such needs exceed the services included in the individual's room and board arrangements with the service provider.

Supports may be provided individually or simultaneously to more than one person living in the home, depending on the required support.

Service Units and Service Limitations: 1 day Independent Living Support Service description: Independent living support is provided to adults (18 and older) and offers skill-building and support to secure a self-sustaining, independent living situation in the community and/or may provide the support necessary to maintain those skills.

Individuals typically live alone or with roommates in their own homes or apartments.

These services are not provided in licensed homes. The supports are provided in a person’s residence or in community settings. There must be a backup plan for times when independent living supports cannot be provided as regularly scheduled.

Allowable activities include but are not limited to:

• Skill-building and support to promote community inclusion
• Increasing social abilities and maintaining relationships
• Increasing or maintaining health, safety and fitness
• Improving decision-making and self-determination
• Promoting meaningful community involvement
• Developing and supporting with daily needs Service units and service limitations: 1 month unit up to 21 hours a week.

Individual and Family/Caregiver Training Service description: Family/caregiver training provides training and counseling services to families or caregivers of those who use waiver services. For purposes of this service, "family" is defined as the unpaid people who live with or provide care to an individual served on the waiver, and may include a parent, spouse, children, relatives, foster family, or in-laws. "Family" does not include people who are employed to care for the individual. All family/caregiver training must be included in the individual's written plan of care.

7.5.24 53 Allowable activities include:

• Participation in educational opportunities designed to improve the family's or caregiver’s ability to give care and support
• Participation in educational opportunities designed to enable individuals to gain a better understanding of their disabilities or increase their self-determination/self-advocacy abilities The need for the training and the content of the training in order to assist family or caregivers with maintaining the individual at home must be documented in the plan of care. The training must be necessary in order to improve the family or caregiver's ability to give care and support.

Service units and service limitations: 80 hours per plan of care year, billed hourly.

In-Home Support Services Service description: In-home support services are residential services that take place in someone’s home, family home, or community setting and typically supplement the care provided by the individual, family, or other unpaid caregiver. In-home support services are designed to ensure the health, safety, and welfare of the individual.

Allowable services include:

• Skill-building
• Routine supports
• Safety supports, any of which enable an individual to acquire, retain, or improve the self-help, socialization, and adaptive skills necessary to reside successfully in home and community-based settings It is permissible to bill this service for up to three people at a time (e.g., siblings); however, the per person reimbursement rate decreases with each additional individual. A backup plan for times when in-home supports cannot be provided as regularly scheduled must be in place.

Service units and service limitations: 1 hour; up to 3 people during a single time period.

Peer Mentor Supports Service description: This service is delivered to waiver recipients by other individuals with DD who are or have been service recipients, have shared experiences with the individual, and provide support and guidance. The service is designed to foster connections and relationships which build individual resilience. Peer mentor supports encourage individuals with DD to share their successful strategies and experiences in navigating a broad range of community resources beyond those offered through the Waiver with Waiver participants so that the Waiver participant is better able to advocate for and make a plan to achieve integrated opportunities and experiences in living, working, socializing, and staying healthy and safe, as well as to overcome personal barriers which are inhibiting

1. 5.24 54 the individual from being more independent. Peer mentoring is intended to assist with empowering the individual receiving the service. This service is delivered based on the support needs of the individual as outlined in the person-centered plan. This service is designed to be short-term and periodic in nature.

Allowable activities include:

• The administering agency facilitates peer to peer "matches" and follows up to assure the matched relationship meets the individual’s expectations
• The peer mentor has face-to-face contact with the individual to discuss specific interests/desired outcomes related to realizing greater independence and the barriers to achieving them
• The peer mentor explains community services and programs and suggests strategies to the individual to achieve desired outcomes, particularly related to living more independently, engaging in paid employment, and expanding social opportunities in order to reduce the need for supports from family members or paid staff
• The peer mentor provides information from experience to help the individual with problem-solving, decision-making, developing supportive community relationships, and exploring specific community resources that promote increased independence and community integration;
• The peer mentor assists the individual in developing a personal plan for accessing the identified integrated community activities, supports, services, and/or resources Service Units and Service Limitations:

1. Peer mentor supports is expected to be a short, periodically intermittent, intense service associated with a specific outcome. Peer mentor supports may be authorized for up to 6 consecutive months, and the cumulative total across that timeframe may be no more than 60 hours in a plan year.
2. The peer mentor shall not supplant, replace, or duplicate activities that are required to be provided by the SC. Prior to accessing funding for this waiver service, all other available and appropriate funding sources shall be explored and exhausted.
3. Peer mentors cannot mentor their own family members.
4. Peer mentors shall be at least 21 years of age and may provide these supports only to individuals 16 years of age and older.
5. Individuals who receive supports through DD or other Waivers may be peer mentors.

Personal Assistance Service description: Personal assistance services provide direct support with activities of daily living, instrumental activities of daily living, access to the community, monitoring of self-administered medications or other medical needs, monitoring of health status and physical condition, and work-related personal assistance. These services may be provided in home and community settings to maintain the health status and functional skills necessary to live in the community or participate in community activities. Personal assistance services may be consumer/self-directed (CD) or agency-directed. If self-directed, a services facilitator is needed.

Each individual and family/caregiver, family, or caregiver shall have a back-up plan for needed supports in case the personal assistant does not report for work as expected or terminates employment without prior notice.

7.5.24 55 Allowable activities include:

1. Support with activities of daily living (ADLs), such as bathing or showering, using the toilet, routine personal hygiene skills, dressing, transferring, etc.
2. Support with monitoring health status and physical condition
3. Support with medication and other medical needs
4. Supporting the individual with preparation and eating of meals
5. Support with housekeeping activities, such as bed making, dusting, and vacuuming, laundry, grocery shopping, etc.
6. Support to assure the safety of the individual
7. Support needed by the individual to participate in social, recreational and community activities
8. Assistance with bowel/bladder programs, range of motion exercises, routine wound care that does not include sterile technique, and external catheter care when properly trained and supervised by an RN
9. Accompanying the individual to appointments or meetings Personal Assistance is not available to those who: o Use group home residential services o Use sponsored residential services o Use supported living residential services o Live in assisted living facilities o Receive comparable services through another program Service units and service limitations: Ratio 1:1; 1 hour unit; not compatible with congregate services.

Personal Emergency Response System Service Description: Personal emergency response system (PERS) is an electronic device and monitoring service that enable certain individuals to secure help in an emergency. PERS services shall be limited to those individuals who live alone or are alone for significant parts of the day, who have no regular caregiver for extended periods of time, and who would otherwise require extensive routine supervision.

PERS services may be authorized when there is no one else in the home with the individual who is competent or continuously available to call for help in an emergency. Medication monitoring units must be physician-ordered and are not considered a stand-alone service. Individuals must be receiving PERS services and medication monitoring services simultaneously.

Service units and service limitations: One month unit.

Private Duty Nursing Service description: Private duty nursing is individual and continuous care (in contrast to part-time or intermittent care) for individuals with a serious medical condition and/or complex health care need, certified by a physician as medically necessary to enable the individual to remain at home, rather than in a hospital,

1. 5.24 56 nursing facility or ICF-IID. Care is provided by a RN or a licensed practical nurse (LPN) under the direct supervision of a RN.

These services are provided at a person’s place of residence or other community settings.

Allowable activities include, but are not limited to:

• Monitoring of an individual's medical status and
• Administering medications and other medical treatment Service units and service limitations: 15 minutes Respite Service description: Respite services are specifically designed to provide temporary, substitute care for care that is normally provided by the family or other unpaid, primary caregiver. Services are provided on a short-term basis because of the emergency absence or need for routine or periodic relief of the primary caregiver.

Such services may be provided in home and community settings to maintain health status and functional skills necessary to live in the community or participate in community activities. When specified, such supportive services may include assistance with instrumental activities of daily living (IADLs).

Respite services may be consumer/self-directed or agency-directed. If self-directed, a services facilitator must be used.

Service units and service limitations: 1 hour unit up to 480 hours per fiscal year, for unpaid primary caregivers only Shared Living Service description: Shared living means an arrangement in which a roommate resides in the same household as the person who uses Waiver services and provides an agreed-upon, limited amount of supports in exchange for Medicaid funding the portion of the total cost of rent, food, and utilities that can be reasonably attributed to the live-in roommate. For those 18+.

Shared Living supports include: o Fellowship such as conversation, games, crafts, accompanying the person on walks, errands, appointments and social and recreational activities o Enhanced feelings of security which means necessary social and emotional support inside or outside of the residence o Personal care and routine daily living tasks that do not exceed 20% of companionship time such as meal preparation, light housework, assistance with and the physical taking of medications

1. 5.24 57 Service units and service limitations: 1 month Skilled Nursing Service description: Skilled nursing is defined as part-time or intermittent care that may be provided concurrently with other services due to the medical nature of the supports provided. These services shall be provided for individuals enrolled in the Waiver having serious medical conditions and complex health care needs who do not meet home health criteria but who require specific skilled nursing services which cannot be provided by non-nursing personnel. Skilled nursing services may be provided in the individual's home or other community setting on a regularly scheduled or intermittent basis. It may include consultation, nurse delegation as appropriate, oversight of direct support staff as appropriate, and training for other providers.

Allowable activities include, but are not limited to:

• Monitoring of an individual's medical status or
• Administering medications and other medical treatment.

Training, consultation, nurse delegation, or oversight of family members, staff, and other persons responsible for carrying out an individual's support plan for the purpose of monitoring the individual's medical status and administering medications and other medically-related procedures consistent with the Nurse Practice Act [18VAC90-20-10 et seq., by statutory authority of Chapter 30 of Title 54.1, Code of Virginia] Service units and service limitations: 15 minutes Sponsored Residential Service description: Sponsored residential services take place in a licensed or DBHDS-authorized sponsored residential home. These services shall consist of skill-building, routine supports, general supports, and safety supports, provided in a licensed or approved residence that enable a person to acquire, retain, or improve the self-help, socialization, and adaptive skills necessary to reside successfully in home and community-based settings.

Sponsored residential services shall be authorized for Medicaid reimbursement in the person-centered plan only when the individual requires these services and when such needs exceed the services included in the individual's room and board arrangements with the service provider.

Sponsored residential services are provided to the individual in the form of continuous (up to 24 hours per day) services performed by the sponsor family. Sponsored residential support includes the expectation of the presence of a skills development (formerly called training) component, along with the provision of supports as needed.

These supports may be provided individually or simultaneously to up to two individuals living in that home, depending on the required support.

Service units and service limitations: 1 day; support to no more than 2 individuals

1. 5.24 58 Supported Employment Service description: Supported employment services are ongoing supports to those who need intensive ongoing support to obtain and maintain a job in competitive, customized employment, or self-employment (including home-based self-employment) for which an individual is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.

• Individual supported employment is support usually provided one-on-one by a job coach in an integrated employment or self-employment situation. The outcome of this service is sustained paid employment at or above minimum wage in an integrated setting in the general workforce in a job that meets personal and career goals.
• Group supported employment is defined as continuous support provided by staff in a regular business, industry, and community setting to groups of two to eight people with disabilities and involves interactions with the public and with co-workers without disabilities. Examples include mobile crews and other business-based workgroups employing small groups of workers with disabilities in the community. Group supported employment must be provided in a manner that promotes integration into the workplace and interaction between people with and without disabilities in those workplaces.

Allowable activities include but are not limited to:

• Job-related discovery or assessment
• Person-centered employment planning
• Negotiation with prospective employers
• On-the-job training, evaluation and support
• Developing work-related skills
• Coverage for transportation when necessary
• Both the individual and group model must be in an integrated setting Service units and service limitations: Individual model is 1:1; group model in groups with 8 or less; 1 hour up to 40 hours per week.

Supported Living Service description: Supported living takes place in an apartment [or

other

residential]

setting operated by a DBHDS-licensed provider. These services shall consist of skill-building, routine supports, general supports, and safety supports, that

enable an individual to acquire, retain, or improve the self- help, socialization, and adaptive skills necessary to reside successfully in home and community- based settings.

This service takes place in a

residential

setting

operated

by

a

DBHDS - licensed

provider.

Two

modes

of

delivery

include

a

Supervised

Living

Residential

Service

License

in

a

provider

owned/managed, licensed setting or in a person's own home under a

Supportive

In-home

Service

License.

Supported living residential services are provided to the individual in the form of around-the-clock availability of staff services performed by paid staff who can respond in a timely manner. These supports may be provided individually or simultaneously to more than one individual living in that home, depending on the required support.

7.5.24 59 Allowable activities include, but are not limited to:

• Using community resources
• Personal care activities
• Developing friends and having positive relationships
• Building skills
• Daily activities in the home and community
• Supporting to be healthy and safe Service units and service limitations: 1 day; may be provided individually or simultaneously to more than one individual living in that home, depending on the required support Therapeutic Consultation Service description: Therapeutic consultation is designed to assist the individual’s staff and/or the individual's family/caregiver, as appropriate, with assessments, plan design, and teaching for the purpose of assisting the individual enrolled in the waiver.

The specialty areas are:

• Psychology
• Occupational therapy
• Speech and language pathology
• Physical therapy
• Behavioral consultation
• Rehabilitation engineering
• Therapeutic recreation The need for any of these services shall be based on the PC ISP and shall be provided to those individuals for whom specialized consultation is clinically necessary and who have additional challenges restricting their abilities to function in the community. Therapeutic consultation services may be provided in individuals' homes and in appropriate community settings (such as licensed or approved homes or day support programs) as long as they are intended to advance individuals' desired outcomes as identified in their ISPs.

Service units and service limitations: 1 hour Required training: DBHDS requires training that covers 2021 regulatory changes to therapeutic consultation behavioral services. TCBS Training is available on the COVLC. A CSB Staff Account registration guide is available to assist with setting up an account if needed. Search for behavioral service providers here.

Transition Services Service description: Transition services are non-recurring setup expenses for those who are transitioning from an institution or licensed/certified provider-operated living arrangement to a living arrangement in a private residence where the person is directly responsible for living expenses.

Transition services are furnished only to the extent that they are reasonable and necessary as determined and clearly identified in the service plan, and the person is unable to meet such expenses or when the services

1. 5.24 60 cannot be obtained from another source. Transition services do not include monthly rental or mortgage expenses, food, regular utility charges, and/or household items that are intended for purely diversional/recreational purposes. This service does not include services or items that are covered under other waiver services such as environmental modifications or assistive technology.

Allowable costs include, but are not limited to:

• Security deposits that are required to obtain a lease on an apartment or home
• Essential household furnishings required to occupy and use a community domicile, including furniture, window coverings, food preparation items, and bed and bath linens
• Setup fees or deposits for utility or services access, including telephone, electricity, heating, and water
• Services necessary for the individual's health, safety, and welfare such as pest eradication and one-time cleaning prior to occupancy
• Moving expenses
• Fees to obtain a copy of a birth certificate or an identification card or driver's license
• Activities to assess need, arrange for, and procure needed resources Service units and service limitations: Up to $5,000 lifetime expended within 9 months of authorization Workplace Assistance Service description: Workplace assistance services are supports provided to people who have completed job development and completed or nearly completed job placement training but require more than typical job coach services to maintain stabilization in their employment. Workplace assistance services are supplementary to the services rendered by the job coach; the job coach still provides professional oversight and job coaching intervention.

The provider provides on-site rehabilitative supports related to behavior, health, time management, or other skills without which the individual’s continued employment could be endangered. The provider is able to support the person related to personal care needs as well; however, this cannot be the sole use of workplace assistance services.

• The activity must not be related to training for work skills which would normally be provided by a job coach
• Services are delivered in their natural setting (where and when they are needed)
• Services must facilitate the maintenance of and inclusion in an employment situation Service units and service limitations: Ratio is 1:1; 1 hour up to 40 hours per week.

Patient Pay Some individuals who are approved for Medicaid under eligibility rules unique to Waiver recipients may have a patient pay responsibility. Patient pay refers to an individual’s obligation to pay towards the cost of long- term services and supports if the individual’s income exceeds certain thresholds. This means that Virginia reduces its payment for DD Waiver services by the amount of the individual’s income remaining after all allowable deductions are made for “personal maintenance needs.”

7.5.24 61 Patient pay is determined by the LDSS using the following methodology:

• The allowable income level used for waivers is 300% of the current supplemental security income (SSI) payment standard for one person.
• Under the DD Waivers, the coverage groups authorized under the Social Security Act are considered as if the individual were institutionalized for the purpose of applying institutional deeming rules. All individuals under the Waivers must meet the financial and nonfinancial Medicaid eligibility criteria and meet the level-of-care criteria for an ICF/IID. The deeming rules are applied to Waiver-eligible individuals as if the individuals were residing in an ICF/IID or would require that level of care.
• The Commonwealth will reduce its payment for DD Waiver services provided to an individual by that amount of the individual's total income, including amounts disregarded in determining eligibility, that remains after allowable deductions for personal maintenance needs, other dependents, and medical needs have been made according to federal guidelines. DMAS will reduce its payment for DD Waiver services by the amount that remains after the following deductions:
• For individuals to whom § 1924(d) of the Social Security Act applies and for whom the Commonwealth waives the requirement for comparability pursuant to § 1902(a)(10)(B), DMAS will deduct the following in the respective order:
• The basic maintenance needs for an individual under the DD Waivers, which is equal to 165% of the SSI payment for one person. Due to expenses of employment, a working individual will have an additional income allowance. For an individual employed 20 hours or more per week, earned income will be disregarded up to a maximum of both earned and unearned income up to 300% of SSI; for an individual employed at least four hours but less than 20 hours per week, earned income will be disregarded up to a maximum of both earned and unearned income up to 200% of SSI. If the individual requires a guardian or conservator who charges a fee, the fee, not to exceed an amount greater than 5% of the individual's total monthly income, will be added to the maintenance needs allowance. However, in no case will the total amount of the maintenance needs allowance (basic allowance plus earned income allowance plus guardianship fees) for the individual exceed 300% of

SSI.

• For an individual with only a spouse at home, the community spousal income allowance determined in accordance with the Social Security Act.
• For an individual with a family at home, an additional amount for the maintenance needs of the family determined in accordance with the Social Security Act.
• Amounts for incurred expenses for medical or remedial care that are not subject to payment by a third-party including Medicare and other health insurance premiums, deductibles, or coinsurance charges, and necessary medical or remedial care recognized under state law but not covered under the State Plan for Medical Assistance.

1. 5.24 62

• For individuals to whom § 1924(d) d o e s not apply and f o r whom the Commonwealth waives the requirement for comparability pursuant to 1902(a)(10)(B), DMAS will deduct the following in the respective order:
• The basic maintenance needs for an individual under the DD Waivers, which is equal to 165% of the SSI payment for one person. Due to expenses of employment, a working individual will have an additional income allowance. For an individual employed 20 hours or more per week, earned income will be disregarded up to a maximum of both earned and unearned income up to 300% of SSI; for an individual employed at least four but less than 20 hours per week, earned income will be disregarded up to a maximum of both earned and unearned income up to 200% of SSI. If the individual requires a guardian or conservator who charges a fee, the fee, not to exceed an amount greater than 5% of the individual's total monthly income, will be added to the maintenance needs allowance. However, in no case will the total amount of the maintenance needs allowance (basic allowance plus earned income allowance plus guardianship fees) for the individual exceed 300% of SSI.
• For an individual with a dependent child, an additional amount for the maintenance needs of the child, which is equal to the Title XIX medically needy income standard based on the number of dependent children.
• Amounts for incurred expenses for medical or remedial care that are not subject to payment by a third-party including Medicare and other health insurance premiums, deductibles, or coinsurance charges, and necessary medical or remedial care recognized under state law but not covered under the State Plan for Medical Assistance.

DMAS will reimburse the providers only for services that are not covered by the patient pay.

The patient pay determination is initiated when an individual’s SC notifies the LDSS via the DMAS-225 that the individual has been approved for DD Waiver services or the individual receiving DD Waiver services experiences a change in circumstances, income, or assets.

The LDSS will determine an individual’ s patient pay amount obligation into the Medicaid management information system (MMIS) or other Medicaid informational system adopted by the administering Medicaid agency at the time action is taken as a result of an application for Waiver services, redetermination of eligibility, or reported change in an individual’s situation. That amount is transmitted electronically to the Medicaid enrollment and claims system.

If an individual receiving DD Waiver services has a patient-pay amount, a provider is designated to collect the patient pay. Providers designated to collect patient pay are responsible for collecting the patient pay amount and reducing the claim for Medicaid payment of DD Waiver services by that amount.

Verification of an individual’s patient pay obligation will be available through the web-based automated response system (ARS) and telephone-based MediCall system. Responsible providers, as designated by the SC, must monitor the ARS/MediCall systems in order to determine the appropriate amount of patient pay to collect. These verification systems allow the provider to access information regarding Medicaid eligibility, claims status, check status, service limits, service authorization,

and pharmacy prescriber identification.

1. 5.24 63 The website to enroll for access to this system is https://rb.gy/76e7sn. The MediCall voice response system will provide the same information and can be accessed by calling 1-800-884-9730 or 1-800-772-9996. Both options are available at no cost to the provider. Information regarding how to access these systems is included in Chapter 1 of each provider manual.

The DMAS-generated notice of approval of pre-authorized services serves as the provider’s individual eligibility and authorization to bill for Waiver services. Only the cost of medically necessary, individual-specific, customized, non-covered items or services may be deducted from the patient pay by the eligibility worker.

The assigned provider should include the patient pay on the claim. Providers must submit claims for all services, even if the provider does not expect reimbursement for a claim due to patient pay. MMIS is only able to track patient pay when a claim is submitted. Providers are responsible for collecting only the amount of patient pay that is deducted from their claim.

PATIENT PAY CONSUMER DIRECTED SERVICES The only exception to application of patient pay rules stated above is for those choosing to self- direct their consumer-directed services.

Agency providers need to document how the actual patient pay amount was obtained. The fiscal agent is responsible for ensuring the patient pay amount is withheld from CD reimbursement.

MEDICAID LTC COMMUNICATION DOCUMENT (DMAS-225) It is the responsibility of the Support Coordinator to complete the DMAS-225 form. The form is sent to the LDSS for review by an eligibility worker and determination on patient pay responsibility. The DMAS-225 is then sent back to the Support Coordinator. The Support Coordinator will review the DMAS-225 and, for individuals who have a patient pay obligation, identify the provider with the highest potential billing amount and inform the provider in writing that they must collect the patient pay.

The DMAS-225 will be used to advise the LDSS staff which provider is responsible for collecting the individual’s patient pay obligation. The Support Coordinator, should complete the Provider NPI# (or API) data field on the DMAS-225. The DMAS-225, when completed by the LDSS, will then be used to inform the Support Coordinator of the individual’s eligibility status.

Once a responsible provider is identified, the Support Coordinator forwards a computer-generated confirmation of level of care eligibility and the DMAS-225 (with the top portion completed) to the LDSS indicating that the individual has met the level of care requirements and providers have been selected.

Following verification that the individual has been screened and approved to receive DD Waiver services, the LDSS eligibility worker will determine the individual’s Medicaid eligibility, complete the LDSS portion of the DMAS-225 and return it to the Support Coordinator with the bottom section completed, showing confirmation of the individual’s Medicaid identification number and the date on which the individual’s Medicaid eligibility was effective.

1. 5.24 64 The SC must maintain a copy of the Department of Social Services (DSS)-completed DMAS-225 in the individual’s support coordination file.

The SC may monitor the ARS/MediCall systems for financial eligibility and patient pay obligations. DSS is responsible for notifying the SC if the individual no longer meets eligibility requirements and for updating the SC of changes to an individual’s eligibility.

The DMAS-225 is also used by the SC and the LDSS to exchange information that may affect the eligibility status of an individual. The SC must complete an updated DMAS-225 and forward it to the LDSS eligibility worker whenever an individual experiences any of the following:

• A change in address
• A change in provider of support coordination services
• An increase or decrease in monthly income
• A change in collector of patient pay
• Discharge from all DD Waiver services
• An interruption in all DD Waiver services for more than 30 consecutive days
• Death The SC must update the DMAS-225 and submit it to the LDSS within 5 business days following any of these changes. The exact change in circumstances and reason for the change must be clearly noted on the

DMAS-225.

Commonwealth Coordinated Care Plus Waiver A Medicaid managed care program includes the CCC plus Waiver (CCC+). This Waiver combined what was formerly the elderly and/or disabled with consumer direction Waiver (EDCD) and the assisted technology (AT) Waiver. The CCC+ Waiver is administered by DMAS.

CCC+ is an integrated delivery model that includes medical services, behavioral health services, and long-term services and supports (LTSS).

People eligible are those who:

• Meet the nursing facility (NF) level of care criteria that is determined using the uniform assessment instrument (UAI) or are dependent upon technological support and require substantial, ongoing skilled nursing care
• If under age 65, must also have a disability (Note: mental illness solely does not qualify as a disability for this waiver);
• Can have their health, safety, and welfare safely maintained in the home when the nurse or personal care aide is not present
• Are determined to be at imminent risk of NF placement

1. 5.24 65

• Are determined that community- based care services under the waiver are the critical services that enable them remain at home rather than being placed in a NF Review, Add, Change Service Providers Once a person with a new DD Waiver slot has chosen service providers, the SC is responsible for adding the chosen providers into WaMS prior to the authorization of services. Service providers cannot access an individual in WaMS until the CSB has added the provider(s). Attachments related to the PC ISP are then loaded into WaMS in preparation for the authorization process. More detailed instructions on how to add, remove and change service providers can be found in the WaMS CSB user guide section 11.

Service Authorization (SA) Service authorization (SA) of DD Waiver services is completed in WaMS. The overall process for requesting SA is as follows:

• SC creates the SA in WaMS
• Provider adds services to SA
• SC Reviews/adds/changes as needed
• DBHDS staff approves, rejects, denies, or pends SA
• MES processes the SA Note: SCs complete SAs for environmental mods, PERS, and assistive technology as the provider if the CSB/BHA is licensed to be a provider of these services and chooses to act as the provider. Please check with a supervisor for information on particular CSB/BHA policy and procedures.

Two approvals need to happen:

• A financial application for adult Medicaid and appendix D must be completed requesting long-term care and given to the local DSS
• The UAI needs to be completed by the Department of Health (DOH). A social worker from DSS or nurse from the local DOH contacts the applicant to schedule an appointment.

More information about the CCC+ Waiver.

More detailed instructions of how to create SAs can be located in section 12 of the WaMS user guide.

Access Representatives from DOH and local DSS screen people to determine if they meet the qualifications to use this Waiver. The screening team includes a DOH nurse and a DSS representative. They use the UAI to determine if someone meets the required functional dependencies, medical/nursing needs, and are at risk of nursing home placement. Screenings may also take place when someone is hospitalized.

1. 5.24 66 Working with MCO Care Coordinators Virginia has six (6) Managed Care Organizations available for the CCC+ Waiver. CCC Plus: Health Plans are located on the DMAS website under the link entitled CCC Plus MCO member services contact information.

Each health care plan offered under the CCC+ Waiver will provide a care coordinator to work with the participant and doctors to create an individualized health care plan that includes among other things, individual outcomes and needed supports and services.

1. 5.24 67 Each person using CCC+ will also take part in a Health Risk Assessment that entails a survey in which the participant is asked health questions. The questions are meant to better serve a person and the information gathered guides the Care Coordinator/MCO when providing health related education.

If someone uses the CCC+ Waiver, it is important that the Support Coordinator and Care Coordinator collaborate and coordinate supports and services. In addition, if a Support Coordinator believes someone would qualify for the CCC+ Waiver, they can assist them and their family with the application process.

Introduction Support coordination services aim to assist people with disabilities to utilize services while also becoming more independent and active in community life. SCs establish a positive and respectful relationship with people and their support networks. Support coordination starts with a person-centered planning process based on the preferences and needs of the people using services.

Person-centered planning is a set of approaches designed to assist people to plan their life and supports. It is a planning process that focuses on the needs and preferences of the person -- not the system -- and empowers and supports people in defining the direction for their own lives. Person-centered planning promotes self- determination, community inclusion, and independence.

The key areas for consideration in person-centered planning are:

• What are the things that are important to and for a person?
• Who are the important people in a person’s life?
• What are the person’s strengths or gifts?
• What is important to the person now and in the future (their dreams)?
• What kinds of support does the person need to achieve the life they want?
• What do we need to do to support the person?

Linking to Services When people receive a DD Waiver slot, SCs need to have a conversation with them about the life they want to live and the supports they might need to access in order to achieve their vision of a good life. In order to link people with appropriate resources, SCs must be knowledgeable about community resources that are available and should maintain regular contact with these resources in order to facilitate access and stay informed.

Many CSBs create and maintain shared information files internally about available resources and service providers, including medical, housing, residential, vocational and employment, community and civic, and spiritual resources. The SC should check with a supervisor to obtain access to resource guides. DBHDS and DMAS also maintain online lists of providers throughout the state of Virginia for persons seeking services outside their region. SCs can also access the My Life My Community Website, the DBHDS Licensed Provider Location Search , or the DMAS provider search to look for service providers in their region.

Support Coordination Process: Plan Development and Implementation

1. 5.24 68 Touring/Visiting Providers When a person expresses interest in exploring new services, they may be ready to begin touring and visiting potential service providers. The SC can play a key role by doing the following:

• Provide the person with information about all available services and qualified providers
• Provide contact information for reaching the organization
• Support the person in making the initial contact
• As necessary, contact the organization and accompany the person to the first meeting
• Make sure the person has the ability to access and utilize the service or resource
• Follow up as needed to address any barriers to access and ensure a successful connection Virginia Informed Choice form (DMAS-460) When a person who uses a DD Waiver is considering options for services, the SC must offer the person a choice of all services available to them, as well as a choice of all of the providers qualified and willing to provide the desired services, including SC services and individual SCs. After making sure that the person has been given the opportunity to make an informed choice, the SC must document this by reviewing and completing the Virginia informed choice form DMAS-460.

An SC can ensure informed choice by doing the following:

• Identify the needed resource and the person’s preferences
• Review existing services and providers and person’s satisfaction
• Discuss all available options and choices (especially more integrated options such as independent living, employment, and community engagement)
• When the person chooses a service, explain, in an understandable manner, the nature of the chosen services, any alternative services that might be advantageous for them, and any accompanying risks or benefits of the proposed and alternative services.

Referrals A referral is the process by which a SC helps a person apply to use a service or other resource. Once a person has made a choice of service providers, the SC will work with the person and the service provider to share pertinent documentation, such as assessment information, service preference, and any other documentation the provider may request. The SC needs to ensure that a signed consent to exchange information has been completed for each new service provider before providing information about the individual.

Annual Eligibility Determination The VIDES must be completed every 12 months in order to document the individual’s continued eligibility and need for support coordination services and DD Waiver services. The annual VIDES must be completed prior to the ISP meeting, but no later than 12 months after the previous year’s VIDES. For example, for a 10/1/24 and

10/1/25 ISP:

1. 5.24

Previous VIDES Annual VIDES Compliant? 8/10/24 8/29/25 Yes, same month 8/10/24 9/7/25 No, exceeds 12 month requirement

8/10/24 5/12/25 Yes, but is earlier than recommended for planning

69 If completed in the same month as the previous year’s VIDES, it is considered to meet compliance (e.g., 2024 VIDES was completed on August 10th and 2025 VIDES is completed on August 29th).

How to Utilize Assessment Information to Begin Plan Development The assessment process includes the completion of the SIS®, the risk awareness tool, the crisis risk assessment tool, and parts I and II of the PC ISP (personal profile and essential information). Other assessments that should be reviewed may include medical reports, school reports, and psychological evaluations.S Effective assessments start with prioritizing the person’s immediate concerns. It is important for a SC to pay attention to any immediate health and safety issues, risk, or risks of harm which can include:

• Medical conditions
• Risks and potential risks
• Restrictive protocols
• Special supervision requirements
• Other presenting needs, as expressed by the person and/or the team and as documented in the referral information
• The strengths and preferences of the person and resources that might be available Conducting assessments is about eliciting personal stories. Since they are the expert on their life, most information gathered should be from the individuals and supporters who know the individual best, which may include their substitute decision maker, if applicable. When using the assessment to begin plan development, it is important to:
• Listen to concerns without interrupting
• Respect preferences, needs, and values
• Use the assessment interview to begin to engage the person served
• Help the person identify strengths, resources, interests, and preferences
• Include the family and other supporters with the person’s permission
• Determine together the person's support needs
• Share the findings from the assessment with the person seeking services Once the assessment is complete, it is time to move on to the development of the plan.

1. 5.24 Note: completion in the same month, no more than 2 months prior to the effective date of each ISP is recommended. 70 Person-Centered Planning and the Team Meeting Once a person has chosen initial services and supports, and again on at least an annual basis, the SC should arrange for a team meeting. The team consists of the person, the SC, and the provider(s) at a minimum and should also include people who are chosen by the person and who know the person best. The person with whom a plan is being developed is always at the center of the planning process. The degree of his involvement depends on his desire to participate, along with the extent to which they are able to participate.

When planning with someone, it is best to bring together a group of people that want to contribute their time and talents because they know and care about the person and want to help them identify and achieve their goals. The CMS Home and Community Based Settings (HCBS) regulations require that the person-centered planning process:

• Is driven by the individual
• Includes people chosen by the individual
• Provides necessary information and support to the individual to ensure that the individual directs the process to the maximum extent possible
• Is timely and occurs at times/locations of convenience to the individual Given these requirements, it is not acceptable for the SC or any provider to schedule meetings and inform the person. Rather, SCs and providers should work with the person to support them to drive the scheduling process. This may require some flexibility on the part of the SCs and providers, but, remember, meetings and plans belong to the people using services.

Annual person-centered planning meetings should ideally be held at least six weeks prior to the due date of the PC ISP. This timeframe allows for last minute rescheduling as well as time for SCs and providers to write their parts of the plan, individuals (and substitute decision makers, as appropriate) to approve the written plans, and submission for service authorization approvals. Service authorization requests should be submitted 30 days prior to the requested start date but must be no later than 10 days prior.

SCs, providers, and people using services should draft part I personal profile and part II essential information prior to the meeting. All team members contribute to its completion during the annual meeting with a draft or notes or in writing before the meeting. The SC combines the information that is discussed and finalized at the annual meeting. The SC shares the final parts I-IV with the person and all team members following the meeting. The information included in the sections of the personal profile is intended to be gathered through conversations with the person and those that know the person best.

Person-centered planning meetings can often feel like an overwhelming amount of work, and it is tempting to conduct a meeting as if checking everything off a list. However, the only way to write a true person- centered plan is to have robust discussions and gather information about the person and what is important to to him as well as his needs and preferences.

1. 5.24 71 Facilitating Conversation Having conversations is the primary mechanism used in planning, and often it is the SC who facilitates these conversations. It is important to know that gathering information from people who know a person well, professionally or personally, may be done outside of a meeting as long as it is done with informed consent.

As the facilitator, the SC must always keep the person as the focus of the discussion. Starting the meeting by asking team members what they like and admire about the person sets a positive tone for a meeting and allows everyone to be heard and recognized. It is also good to talk first about the good things that have happened in the person’s life since the last meeting. Person-centered planning does not mean we ignore the things that are of concern, but it should not be the initial or primary topic of discussion. While facilitating the meeting, talk directly with the person, rather than talking around and about the person. Ask questions and gather information. When possible, empower the person to share his personal profile with the team and include information about things that are important, what is working and needs to stay the same, and what is not working and needs to change. Team members can offer ideas and suggestions, which can be added to the profile with agreement from the person. SCs should also facilitate a discussion about what the person’s vision for a good life is. A person’s dreams and goals should be a driving force in the plan.

The person and the team should also discuss things that are important to that person (issues of health and safety and being a valued member of one’s community, for example), as well as any risks that have been identified. After ensuring that the person’s needs and preferences have been identified and that the team is supporting the person to find a balance between what is important to and for them, the discussion can address specific, measurable outcomes to include in the shared plan.

Completing the Person-Centered Individual Support Plan (PC ISP) Trainings in the Commonwealth of Virginia Learning Center Prior to completing PC ISP documentation, all SCs should complete the PC ISP training modules in the Commonwealth of Virginia learning center.

7.5.24 72 Parts of Virginia’s PC ISP Virginia’s Person-Centered ISP has 5 distinct parts:

Personal Profile

Essential Information

Shared Planning

Agreements

Plan for Supports Part I- Personal Profile Facilitating a conversation with the person, with input from the rest of the team, is essential in order to gather the information necessary for part I of the plan. The personal profile first outlines the person’s preferences for the meeting and how they prefer to be supported during the meeting, so it is essential that this conversation happens prior to planning the meeting.

The personal profile discusses the person’s talents and contributions. When completing this section, the SC should have discussions with the person, those who know and love them, and providers about the things that people like and admire about the person, as well as the truly great things about them. SCs should consider how they talk about their own friends and family, and how they themselves would want to be introduced to others. Saying things like the person has a great sense of humor and loves sculpting clay is more genuine than listing “disability praise” such as “he ambulates independently.” The next section in the personal profile discusses those things that are important to and for a person.

Remember that “important to” things make the person happy, content, and fulfilled, while “important for” are matters of health and safety and being a valued member of one’s community. These questions should be answered with regard to the seven life areas indicated in the plan: employment, integrated community involvement, community living, safety and security, healthy living, social and spirituality, and citizenship and advocacy.

The next section in the personal profile asks about the life that the person wants. The team should have a discussion with the person about the things that are working well, what should remain the same or be enhanced, and what needs to be changed. The person should be empowered to share his dreams and visions of what he wants his good life to look like The final section of the personal profile asks the opposite question – what are the things that the person does not want in his o life? The person should be supported to openly talk about things that are currently not working or making sense, or things that may not currently exist or be happening that they want to avoid having in their life.

All of the information in the personal profile should be used as a tool to determine what is important to a person and act as a bridge to developing the outcomes in part III of the PC ISP, shared planning.

1. 5.24 73 Part II - Essential Information Part II of the PC ISP, or essential Information, contains a wide variety of information necessary to provide supports to an individual. Part I provides information across the following areas:

• Representation
• Disability Determination
• Health Information
• Behavioral and Crisis Supports
• Medications
• Physical and Health Conditions
• Last Exam Dates
• Allergies
• Social, Developmental, Behavioral and Family History
• Communication, Assistive Technology, and Modifications
• Education
• Employment
• Future Plans
• Review of Most Integrated Settings Part III- Shared Planning Part III of the PC ISP, or shared planning, lists outcomes shared across providers, as necessary, in order to help the person on a path to the life they want. The Part III contains measurable outcomes listing an achievement the individual wants to pursue, the key steps to get there, when it will be accomplished, and who is responsible for helping the person reach that achievement. The shared plan is completed at the annual meeting and contains the outcomes that lead to the life the person wants.

In the development of outcomes, it is important not to lose sight of the purpose of planning, discovering, and setting in place plans to pursue the life the person wants. In shaping outcome statements, three considerations are recommended. Outcomes that are meaningful to the individual can support a person with achieving independence, integration, or an increased quality of life. As outcomes are developed, teams may benefit from asking if the outcome speaks to one of these three areas to determine if the outcome supports the person in a meaningful way.

It is important to remember that services themselves are not outcomes. “Mary goes to day support” is not an outcome. Think about the reasons people go to day support. Is it so they can develop their ability to communicate better, learn to use resources in their community, or develop the abilities they need in everyday life? The service is just what supports individuals to get what matters to them based on their own particular needs and interests.

While the SC is responsible for entering parts I-IV into WaMS, outcomes and key steps to get there are developed at the planning meeting with input from the entire team. SCs do not “assign” outcomes, rather, the person, the SC, the provider, and other planning partners discuss possible outcomes as they relate to the life

1. 5.24 74 that the person wants. Every team member is responsible for contributing to the discussion, and providers should be aware of the allowable activities and limitations of their service when agreeing to outcomes and key steps. It is critical that outcomes and key steps are developed and agreed to by the team during the planning meeting. It may be helpful to write the outcomes and key steps down during the meeting so that everyone knows and agrees who will be supporting the outcomes. Review the Life Areas Cheat Sheet and the Integrated Community Involvement Fact Sheet to learn more about developing outcomes in the shared planning team process.

Part IV- Agreements Part IV, or the agreements section, is an evaluation of the annual planning meeting. It contains questions for the individual and team, as well as a signature page that is signed by all present at the meeting. Answer all questions and record any plans to address or resolve objections. This is also a place to record any inability to meet a request and the related team decision. All parties involved in planning will sign the part IV, and it will serve as the signature page for the plan. Signatures indicate agreement with the plan.

Waiver Management System (WaMS) SCs are responsible for putting all of the information for parts I-IV that was agreed to during the meeting into WaMS. If, in the process of entering the ISP information into WaMS, the SC finds that something is wrong or that they disagree with something, the SC should not just make changes. Instead, the SC should reconvene the team to discuss the issue and obtain team agreement. Likewise, if a provider disagrees with something that the SC wrote in the plan in WaMS, the provider should also reconvene the team to discuss and come to an agreement. Once the SC has entered all parts I-IV into WaMS, it is necessary to ensure that the ISP is in the correct status (either Complete or Pending Provider Input). An ISP with a status of pending SC input is considered to be incomplete.

If changes need to be made to parts I and II after the ISP is complete, the SC may make those changes. If changes need to be made to part III, those changes need to be initiated by the provider. Please see the WaMS user guide for more information.

Part V- Plan for Support (PFS) Part V, or the plan for supports (PFS) is the provider-completed part of the ISP. All service providers must have a PFS that details the activities and support instructions that are expected to lead toward the agreed-upon outcomes. The PFS includes: Support instructions and preferences that are constant in a person’s life

• The individual’s desired o from the shared planning (or a PFS revision)
• The support activities the provider has agreed to provide to support the person with each outcome
• What will be seen or obtained to resolve each activity
• Any additional support instructions needed to complete activities
• A general schedule of supports
• When applicable, documentation of consent for any safety restrictions Avoid Jargon –

1. 5.24 75 When writing plans, use ordinary language rather than professional jargon. SCs can use themselves as a yardstick. If they would not use the same words or descriptions for themselves, then they should not be used to describe someone else. Also remember, the language needs to be understood by the plan owner. Here are just a few examples:

• Instead of “interpersonal skills”, use “easy to get along with”.
• Instead of “ambulates independently”, use “walks on his own” or consider whether this needs to be said at all.
• Instead of “verbal cues or prompts”, use “remind her by saying…”
• Instead of “auditory monitoring distance”, use “within earshot”.
• Instead of “off-task behaviors”, use “distractions”.
• Instead of “on-task behaviors”, use “pays attention”.

How to Write Measurable Outcomes An individual’s desired outcomes should be based on what is important to the person with regard to personal preferences; however, outcomes need to also be written in a way that is measurable. For example, having more spending money might be important to a person but does not establish what this means in measurable terms. In addition to being observable, a few additional considerations can increase measurability of outcomes – the frequency of the outcome, the target date, and the steps that lead to the outcome.

The statement “John has more money” can be improved by considering how this could describe an achievement that John would find meaningful such as: “John saves 50 dollars per month so that he can go on vacation next year,” or “John earns at or above minimum wage for 12 months so that he has more shopping money.” Each outcome in the PC ISP will have a target date noted as “by when,” which indicates that the outcome is expected to be accomplished or will be reassessed by that date. When desired, a frequency should be included in the wording of the outcome statement.

The next step for planners and teams to increase measurability is to describe the basic steps that lead to the outcome. These steps are shared across the planning team to contribute to achieving the outcome. To make an outcome measurable, we would ask, “What are the steps to get there?” These steps lay out the plan to pursue the achievement which is in line with action planning, a foundational person-centered practice. These steps should be logical and, when considered together, be expected to result in the time-bound achievement that is defined in the outcome.

There is a suggested formula for writing meaningful outcomes. This formula has been slightly modified as follows for the examples provided. The asterisk* is a reminder to include a frequency when desired: [Person’s name] [activity/event/important FOR]* so that/in order to [important TO achievement] (From DBHDS person-centered ISP guidance document. For more detailed information and examples, see this document at the Virginia Regulatory Townhall website.

1. 5.24 76 Support Coordination Part V The SC outcome statements from the part III encompass the tasks associated with targeted case management to include linking, monitoring, assessing, coordinating, and planning with an individual. There are often other outcomes in a person’s shared plan that require specific SC actions. These must be included in the SC part V plan for supports alongside any standard global outcome. The SC would then have support activities under each outcome. The support instructions would be specific to how the SC will support the individual.

PFS Approval and Submission When providers complete their part V and submit it in WaMS to the SC, the SC must review the part V to assure that it fulfills all of the requirements for the particular service offered and addresses the identified outcomes and support needs. SCs should pay particular attention to the outcomes, key steps, and support instructions to ensure that the service being provided and the plan for supports are within the scope of the allowable activities for the service, and that the plan does not indicate anything that is indicated as not allowable or a service limitation. For example, skill-building is not allowable in companion services, so the SC should make sure that the companion part V does not include any skill-building activities. If the Part V does not meet the regulatory requirements and limitations for the service, the SC should inform the provider and ask that they make the changes necessary. Allowing time for plan revisions is one of the reasons why it is highly recommended that the planning process begin at least six weeks in advance.

Service Authorizations to Initiate Services Once a person has made an informed decision about support options and chosen service providers, the SC can begin the process of authorizing services in WaMS. It is the responsibility of the SC to ensure that the information in WaMS is up-to-date, add all service providers into WaMS, review all requests, modify the amount or type of services as needed, and submit the service authorization for processing. More detailed information about the initiation of service authorizations can be found in section 12 of the WaMS user guide.

WaMS User Guide At-A-Glance “When to Submit What” At-A-Glance Service Authorization Guidance At-A-Glance How to Evaluate and Document Implementation of a PC ISP Once a PC ISP is complete, it is time to work towards completion of support activities in the SC’s part V, complete documentation regarding progress towards completion of the outcomes, and review that documentation quarterly in a person-centered review.

1. 5.24 77 Throughout the plan year, the SC will work to complete tasks related to supporting a person reach their outcomes as specified in the SC’s plan for support.

Progress Notes An SC is required to complete documentation regarding contacts with the person and significant others in regard to the individual, progress towards outcomes, and significant events including health and safety concerns such as falls, hospitalizations, etc. This documentation, called progress notes, should include specific details, such as full date of contact, who reported the information (name, title, and/or relationship to the individual), place of contact, type of contact, summary of contact (including what the SC did in regard to linking, coordinating, and advocating), and should always have a signature/electronic signature and title of the SC completing the note with the date. Notes are required to be completed on the day the described supports were provided. Documentation that occurs after the date supports were provided shall be dated for the date the entry is recorded, and the date of supports delivery shall be noted in the body of the note.

Person-Centered Review Quarterly, the SC will complete a person-centered review (PCR) according to the schedule indicated in part IV.

This includes not only progress on outcomes for which the SC is responsible but also a summary of the PCRs received from all service providers. Providers have a 10-day grace period after the end of a quarter to complete their PCRs and submit them to the SCs, then SCs have a 30-day grace period after the end of a quarter to complete their PCRs.

The PCR includes information regarding outcome status including a summary of significant events from the quarter in regard to each outcome. If a change to the plan is needed, this will be documented in the PCR.

Additionally, the PCR will include information regarding safety risks identified over the quarter, changes desired or needed regarding supports and services, satisfaction with supports and services, as well as plans to address any dissatisfaction, whether or not all Medicaid services were implemented and how to address them if not, and, finally, any other significant events not included elsewhere in the PCR.

Information in progress notes and PCRs, as well as in continued conversations throughout the year with the individual and team members, will be helpful in preparation for the upcoming plan year.

Regional Support Teams At times, an SC may encounter difficulties or barriers to community supports for someone. In this instance, the Regional Support Team (RST) may offer assistance. RSTs can provide recommendations and assistance in resolving barriers in the most integrated community setting consistent with someone’s needs and informed choice. Submission of RST referrals are required to ensure informed choice and availability of services.

Through referrals, the RST will monitor, track, and trend choice, integrated option availability, and challenges that require further system development. The SC shall notify the Community Resource Consultant (CRC) and RST in the following circumstances: a.) within five calendar days of an individual being presented with any of the following residential options: i. an intermediate care facility, ii. a nursing facility, iii. a training center, or iv. a group home with a licensed capacity of five beds or more; b.) if the CSB is having difficulty finding services within 30 calendar days after the individual's enrollment in the waiver; or c.) immediately when an individual is displaced from his or her residential placement for a second time.

1. 5.24 78 Recommendations from the RST are explored by individuals receiving services and their authorized representatives/substitute decision-makers with assistance of the SC. The recommendations provide opportunities for the individual to choose more integrated options.

PC ISP Training Modules Self-Directed Training Modules are available on the Commonwealth of Virginia Learning Center (COVLC Log In) in the following areas:

• PC ISP Training Development, Module 1 (Parts I and II)
• PC ISP Training Development, Module 2 (Parts III and IV)
• PC ISP Training Development, Module 3 (Part V)

1. 5.24 79 Support Coordination Timelines Through monitoring and evaluations, the SC takes the lead in ensuring that the support team members follow through with the commitment( s) they made to support individuals to reach their desired outcomes. This is accomplished through a number of billable and non-billable activities. It is important to know the difference to assure that a review of progress, satisfaction, and risk not only has been completed, but also that an allowable activity has occurred so that the CSB/BHA can bill for the support provided. To accurately monitor and evaluate each person, there are tasks that will need to occur, depending on the person, every 30, 60, or 90 days. Each SC is responsible for keeping up with timelines and billable activities.

Monthly Contact SCs must conduct a minimum of one contact or activity every month, defined as:

• Direct or individual-related contacts, communication or activity with the individual, their family/caregiver (as appropriate), service provider, or other organization on behalf of the individual The assigned SC will provide support coordination services as frequently and timely as the person needs assistance. There must be at least one documented contact, activity, or communication as designated previously and relevant to the ISP during any calendar month for which support coordination services are billed. SCs are responsible for proactively identifying risks, implementing plans to mitigate previously known and newly identified risks, and resolving them in a timely manner.

Billing will be submitted for an individual only for months in which direct or individual-related contact, activity, or communication occurs and the SC’s records document the billed activity. Service providers will be required to refund payments made by Medicaid if they fail to maintain adequate documentation to support billed activities.

The allowable support activities can include but are not limited to:

• Coordinating initial assessment and annual reassessment of the individual and planning services and supports, to include history-taking, gathering information from other sources, and the development of a PC ISP. This does not include performing medical or psychiatric assessments, but may include referral for such assessment.

CHAPTER 8: Support Coordination Process: Monitoring Billable Activities and Evaluation

1. 5.24 80

• Coordinating services and supports planning with other agencies and providers, including making appointments
• Linking the individual to services and supports specified in the PC ISP
• Assisting the individual directly for the purpose of locating, developing, or obtaining needed services and resources, including crisis supports
• Enhancing community integration by contacting other entities to arrange community access and involvement
• Making collateral contacts with the individual to promote implementation of the PC ISP and successful community adjustment
• Monitoring implementation of the PC ISP through regular contacts with service providers as well as periodic site visits and home visits
• Instruction and counseling which guides the individual in problem-solving and decision-making and develops a supportive relationship that promotes implementation of the PC ISP. Counseling in this context is defined as problem-solving activities designed to enhance an individual’s ability to live in the community. Allowed instructional activities would include discussion about the benefits of the activities listed in the service plan.
• Monitoring the quality of services
• Assisting the individual to secure services in an ICF/IDD if the individual or family member requests institutional placement
• Monitoring the PC ISP to ensure it is implemented as written and making TIMELY referrals, service changes, and amendments to the PC ISP The activity of writing the PC ISP, person-centered review, or progress note is not considered a billable case management activity. However, developing the PC ISP through a team meeting is a billable activity.

There will be no maximum service limits for support coordination services, except for individuals residing in institutions or medical facilities. For these individuals, reimbursement for support coordination will be limited to 90-days pre-discharge (immediately preceding discharge) from the institution into the community. While individuals may require re-entry to institutions or medical facilities for emergencies, discharge planning efforts should be significant to prevent readmission. For this reason, support coordination may be billed for only two 90-day pre-discharge periods in a 12-month period.

Ongoing Assessment/Monitoring In Chapter 2, assessment was identified as the ongoing process of gathering and summarizing information that guides the work between the SC and the person using services. The assessment not only helps to determine initial eligibility for services but ongoing eligibility as well.

Is the PC ISP implemented appropriately?

Monitoring the PC ISP to determine if it is being implemented appropriately involves doing the following activities:

1. 5.24 81

• Actively observe the person and service providers to make sure the plan is being properly implemented, including the completion of the On-site Visit Tool (OSVT)
• Make periodic site and home visits to assess the quality of care and satisfaction
• Make collateral contacts with people who support the individual (with whom there is a signed consent
• to exchange information) in various aspects (school, work, medical, friends, paid providers, family, etc.) to obtain a well-rounded picture of the person
• Consistently support the person in identifying concerns, and modify the plan to reflect concerns and how concerns are addressed as necessary
• Follow up with the individual and support partners to determine if instructions provided by qualified professionals are being followed Regularly meeting with people in their natural environment -- for example their home, day program, or workplace will allow proper assessment of the plan implementation. Keep in mind that visiting someone at a worksite may be considered intrusive by the employer; therefore, the SC should identify alternative ways to monitor that service.

Status of Current Risks and Identifying New Risks Ongoing assessment should include gathering information to make sure health and safety needs are met.

Some risks, like pressure soresincluding decubitus ulcers, can be reduced by understanding who is at risk, recognizing early signs of skin breakdown, and implementing interventions early. While SCs may not see skin breakdown, they can promote risk mitigation by having knowledge of risk factors, who is at risk, and ensure that outcomes are added to the PC ISP to prevent skin breakdown for those at risk. SCs can inquire directly with support personnel and ask to see positioning logs, skin check logs, etc., to further monitor the risk. Prevention is the key! For more information, go to the Department of Behavioral Health and Developmental Services (DBHDS) Office of Integrated Health (OIH) website for the presentation on promoting skin integrity as well as other health and safety information.

The SC should assess the status of current risks and evaluate the person’s current living situation to determine if there are new risks. Some examples of areas the SC may want to pay close attention to are:

• The person’s dietary and nutritional needs;
• The current living situation;
• Activities of daily living (ADLs);
• Risk of suicide or self-harm;
• Social or environmental risk factors (family situation, lack of social support, or isolation); and
• Change in mood or behavior.

The use of the on-site visit tool (OSVT) details the assessment of current risks and new risks. The OSVT is to be completed at the face-to-face visit monthly for people with enhanced case management (ECM) and once per quarter for people with targeted case management (TCM). The OSVT helps ensure consistency for SCs across the state to confirm the ISP is implemented appropriately and the evaluation of a change in status is completed. The form helps guide the SC through a detailed checklist of focus-area questions based on observation and report. When completing the OSVT, SCs need to ensure that every question is answered in order for the assessment to be complete. The findings from the OSVT and any required follow-up actions should be documented in a corresponding case note. Information from this tool/notes should also be included in the quarterly PCR. Access the OSVT online at https://dbhds.virginia.gov/case-management.

7.5.24 82 Ways to Minimize Risks An SC can help to minimize the risks by:

• Identifying strengths (competencies, accomplishments, resources, support network)
• Understanding the capability of service providers to meet the person’s needs and preferences
• Reviewing assessments completing by qualified professionals
• Making referrals as appropriate to help mitigate newly identified risks or potential risks
• Following up with the individual and any support partners to assure plan to mitigate risk are being developed and followed
• Link with assistive technology and environmental modifications as appropriate
• Being knowledgeable of community opportunities and resources
• Helping people make informed decisions
• Ongoing collaboration with the person, family members, and service providers Documenting Newly Identified Needs, Preferences, Supports, and Services When the SC is conducting monthly contacts, face-to-face visits, and PCRs, all newly identified needs, preferences, supports, and services should be documented in the progress notes. The PC ISP is updated when changes occur or new information is discovered, and updates are communicated with others supporting the person. Having ongoing and regular contacts with the person, service providers, and family members, as appropriate, can help the SC assess and identify needed modifications to the PC ISP.

PC ISP Updates When the SC identifies the need to update or modify a PC ISP, they must: o Review current outcomes and make changes to the PC ISP to reflect any modifications, including updating the case management plan for supports o Review modified provider service plans in WaMS (for DD Waiver only) o Submit the modified provider service plan (part V plan for supports) for service authorization if there is a request for a change in hours or service providers o For SC responsibilities related to modifications in service authorizations, use the WaMS CSB User guide section 12 o Update the PC ISP part I personal profile, part II essential information, and part III shared plan (remember the SC can only update the Part III if they are adding or removing a provider from the outcomes. Any other changes to the Part III come from the provider,) as needed o Obtain consent to exchange information forms for any new service providers o Update the informed choice DMAS 460.

1. 5.24 83 Face-to-Face Visits SCs are required to meet with each individual face-to-face at least every 90 days. A 10-day grace period is permitted; however, use of the grace period does not change the original 90-day due date and schedule.

Previous FTF Done Next FTF Due Next FTF Actually Done Compliant? 8/10/21 11/8/21 11/4/21 Yes – within 90 days 11/4/21 1/2/22 1/7/22 Yes – within the 10 day grace period – but next due date reverts back 1/2/22 4/2/22 4/1/22 Yes – within 90 days 6/30/22 7/18/22 No – beyond the 90 days plus 10 day grace period At face-to-face meetings, the SC will:

• Observe and assess for any previously unidentified risks, injuries, needs, or other changes in status
• Assess the status of previously identified risks, injuries, or needs, or other change in status
• Assess whether the person's service plan is being implemented appropriately and remains appropriate for the person
• Assess whether supports and services are being implemented consistent with the person's strengths and preferences and in the most integrated setting appropriate to the person's needs "Face-to-face visit" means an in-person meeting between the Support Coordinator and the individual and family/caregiver, as appropriate, for the purpose of assessing the person's status and determining satisfaction with services, including the need for additional services and supports.

Documentation must clearly state that:

• The SC was in the presence of the person, the date, and the location of the visit.
• Unmet needs were identified, and a plan was developed to address the unmet need, if applicable.
• Satisfaction with services was assessed.
• Status of services was evaluated and adjusted as needed.
• A face-to-face visit occurred, and there are observations or assessments of: o a newly identified need o change in status or preference o an inadequately addressed risk or need o any issues with implementation of the PC ISP

• Then the SC will:

1. 5.24 84 o review and update the PC ISP as needed o develop a mitigation plan o document the issue If any issues are identified during the face-to-face assessment, the individual’s status or preferences have changed, or the PC ISP is not being implemented as written or needs to change, document this in the face-to-face visit note and OSVT.

It may be appropriate to convene a team meeting to review and update the PC ISP. Determine if new services are needed, or if current services/support activities need to be modified. The SC should ensure that the PC ISP is amended when the reassessment indicates that revisions in the plan are needed to address and meet an individual’s changed needs. The ISP should be updated as indicated and should include an implementation schedule for the changes needed to address the individual’s needs.

Any identified issues should be addressed. Remember, the SC is responsible for coordination of services. The SC makes all team members aware of changes or newly identified risks that may affect their implementation of PC ISP outcomes.

Documenting and communicating information is very important. It also confirms and validates that support was provided and received. If an issue is identified, it must be documented along with its resolution and/or the attempts to address barriers.

The SC will conduct a face-to-face visit once every 90 days (with the allowance for a 10-day grace period) unless one of the following criteria are met.* If one of the below criteria are met, the individual meets criteria for enhanced case management.

• Receives services from providers having conditional or provisional licenses
• Has any items scored with a 2 under 1a or 1b on the SIS
• Has an interruption of service greater than 30 days
• Has an inability to access needed therapeutic services, assistive technology, environmental modifications, and/or behavioral consultation
• Encounters the crisis system, including risk triggers, criminal justice system, or APS involvement
• Has transitioned from a training center within the previous 12 months
• Resides in congregate settings of 5 or more individuals** *Some exceptions apply ** exceptions are described in the 2023 Case Management Operational Guidelines available here: https://townhall.virginia.gov/l/GDocForum.cfm?GDocForumID=2099 Enhanced Case Management Review the individual’s need for ECM criteria at each face-to-face AND update as changes occur. ECM criteria will be applied to anyone:

1. 5.24 85

• With a DD Waiver; or
• Receiving TCM and who are on the DD Waiver waitlist and have a CCC+ Waiver For individuals that are receiving ECM, these visits must occur at least one time per calendar month, with no more than 40 days between visits. For example, if an ECM visit occurs on March 2, the next visit is due on or before April 11th. There are 40 days from March 2nd to April 11th and this timeframe enables one visit to occur in both calendar months. Please see below: To assist with determining when to initiate and cease the provision of ECM, DBHDS developed, in collaboration with CSBs, an automated ECM Worksheet that is available for download on the DBHDS website at https://dbhds.virginia.gov/wp-content/uploads/2022/09/CM-Worksheet-FINAL-11.3.21-1.xlsx.

See the 2023 Case management Operational Guidelines to read more about the requirements for ECM and how to meet the requirements successfully. Searching for providers with either a conditional or provisional license can be completed on the DBHDS website.

1. 5.24 86

Transfers between Support Coordinators Within the Same CSB The relationship between SCs and the individuals they support is very important. At times, the individual may feel the need to request a new SC. Licensing regulations dictate that all CSB/BHAs should implement a written policy describing how people are assigned SCs and how they can request a change of their assigned SC. To proactively promote choice, SCs will review choice of providers when service changes occur and include choice of current providers and specific SCs at least annually by completing the Virginia Informed Choice Form (DMAS 460) as required by Medicaid. When a person requests a change in SC, the SC should check with a supervisor to learn the agency’s policy and honor the request from the person for a change in SC whenever possible. Once the change has occurred, it is important for the newly assigned SC to ensure that the record indicates the change in SC. Documentation of this change might include:

• Updating the PC ISP Part I Essential Information section;
• Recording the request from the person in the progress notes;
• Completing the Virginia Informed Choice Form (DMAS 460) to include specific SC name ;and
• Notifying all collateral contacts (family members, providers, professionals, etc.) Transfer Protocols to/from Other CSBs When a person moves to another locality, it may become more challenging for a SC to continue to monitor services. In this instance, the SC should work with the person to transfer support coordination services to another CSB/BHA. For more detailed information about the protocol for transferring support coordination to another CSB/BHA, please see your supervisor and ask for the most current version of the CSB Case Transfer Protocol.

Discharge/Transition Planning All licensed providers, to include CSB/BHAs, are required to have written procedures that define the process for transitioning an individual between or among services operated by the provider. At a minimum the policy shall address:

• Continuity of services during and following transition;
• Participation of the person or authorized representative in planning;
• Process and timeframe for transferring access to the record and ISP
• Process and timeframe for completing the Transfer Summary.

Chapter 9: Support Coordination Process: Transitions of Support

1. 5.24 87

• For more information, read 12VAC35-105-691 (Transition of Individuals Among Services) and 12VAC35-105-693 (Discharge).

Training Center Discharges Anyone who previously resided in the training center who now lives

in

the

community

is

required

to

have

a

more

intensive level of support from

the

SC.

When

a

person

residing

in

the training

center

is

seeking

discharge

into

the

community, the SC plays an important role ensuring a smooth transition. The assessment and discharge plan development process for a person being

discharged

from

the training center

is

similar

to

the

process

for

someone

already residing in the community. Further, there is additional funding available to help someone move into the community. SCs should ask their supervisors for assistance with local funding resources.

Virginia has approved limited

funding

as

a

part

of

the

plan

to

support

individuals

transitioning

from

the training

center or other state facility according to the “community move process” to a community home of their choice.

Transitional funding, formerly known as “bridge funding,” can be used in a variety of ways to support the planning and move of these individuals to their own homes or to a provider home licensed by DBHDS. The application is available on the DBHDS website.

State Psychiatric Hospital Discharge Both CSB/BHAs and state psychiatric hospitals recognize the importance of timely discharge planning and implementation of discharge plans to serve persons in the community as well as to ensure the ongoing availability of state hospital beds for people presenting in the community with acute psychiatric needs.

Please read the collaborative discharge protocols for state psychiatric hospital discharges for more information.

Private Medical/Psychiatric Hospital The SC may support a person who is in a private hospital and is seeking discharge into the community. The SC should work collaboratively with the person, family or guardian, and the hospital staff to assess the person’s needs upon discharge; identify risks, needs and preferences; address barriers; and ultimately develop a plan that meets the person’s desired outcomes. Once the person returns to the community, the SC provides ECM services for one year and then determines if the person continues to meet the criteria for ECM services.

Discharge from Support Coordination There are a number of reasons why a person may be discharged from SC services. Reasons may include, but are not limited to:

• The person moves out of the CSB/BHA catchment area or out of the state;
• Death;
• The person chooses to no longer use support coordination services;
• The person is no longer eligible for support coordination services;
• The person no longer meets financial eligibility for support coordination services; and
• The person no longer has active or specialized need for support coordination services.

1. 5.24 88 It is essential for the SC to work carefully through the transition and discharge process. SCs must ensure there is agreement on ending SC services with the person, the agency, and other appropriate parties. The SC should provide reasonable notice of discharge that is based upon the facts and circumstances of each person’s life.

The SC should document both verbal and written notice to the person leaving services and the other participating service providers. It is important to communicate pertinent information, with permission, when transitioning to other providers and supports to maximize positive outcomes. As part of a discharge summary, the SC will include linkage to other resources as needed for a smooth transition. Documentation includes completion of the required discharge summary, notice of appeal rights, final PCR, and a progress note.

Discharge from Support Coordination responsibilities:

• Complete SC agency’s documentation requirements for discharge (discharge summary, case notes, final PCR, etc.) and submit a notification of right to appeal letter regarding termination, if the person is receiving Medicaid-billed State Plan Option (SPO) TCM.
• When the person moves to another locality in Virginia and the receiving CSB/BHA will continue to provide TCM services an exception to the need for a Notification of Right to Appeal letter exists.

Because the SPO CM will continue, there is no need to send the appeal notification because no Medicaid services will be terminated.

See DBHDS Licensing regulation 12VAC35-105-693 regarding Discharge.

1. 5.24 89

• Complete the Risk Awareness Tool at or prior to the initial Planning meeting and annually thereafter to increase awareness of the potential for a harmful event (e.g., bowel obstruction, sepsis, fall with injury, self-harm, elopement, etc.) to occur and to facilitate the process of taking action to reduce and prevent the risk.
• Complete the Crisis Risk Assessment Tool at intake and every face to face meeting thereafter to capture information that may put an individual at risk for crisis or hospitalization, and to foster proactive referrals to REACH or other appropriate programs if such a risk is determined.
• Complete the Onsite Visit Tool at one face to face meeting with each person, no less than one time per quarter to observe the person and the environment to assess for risks.
• Request copies of and/or results of health risk assessments (HRA) completed annually by CCC+ care coordinators.
• Participate in SIS® meetings.

Cha

pter 10: Hea

lth & Safety Introduction People with disabilities need health care and health programs for the same reasons anyone else does - to stay well, active, and a part of the community. Having a disability does not mean a person is not healthy or cannot be healthy. Being healthy means the same thing for all of us - getting and staying well so we can lead full, active lives. People with disabilities experience all the same common health issues as the general population, yet as a group, they have much greater health needs. People with disabilities can also be at higher risk for injuries and abuse. For these reasons, health and safety are core concerns for people with disabilities, however, these concerns do not override a person’s fundamental right to the dignity of risk, the right to take

risks when engaging in life experiences, and the right to fail in those activities. All too often people are limited

from living their best lives under the guise of health and safety concerns when it is really a lack of a creative, committed effort to provide individualized and meaningful supports.

Resource: Disability and Health Information for People with Disabilities Support Coordinators Role in Health & Safety The Support Coordinator (SC) should perform the same process steps regarding a person’s health and safety that they do for other supports and services for the people they support. Some of the particular duties regarding health and safety are outlined below.

Assessment

1. 5.24 90 Plan Development

• Document risk and medical and behavioral support needs, which can be gathered from a variety of sources to including but not limited to needs as determined by the SIS® assessment, the RAT, the crisis RAT, the onsite visit tool, and the CCC+ HRA.
• Parts III and V on the PC ISP must address all risks and medical and behavioral support needs. For example, assisting a person to obtain a ramp through an environmental modification, linking someone to a psychiatrist to obtain needed mental health support and medication monitoring, linking a person to a physician for an assessment for wound care, etc.
• Review provider Part V plans for supports to ensure they include supports as agreed upon in the shared planning regarding all risks and medical and behavioral needs.

Plan Implementation/Coordination

• Communicate with all providers to share vital information, for example, a residential provider reports that someone he supports has received a new order from his physician that blood sugar levels have to be tested every 2 hours. The day support program will need to be informed so that they can also make sure the blood sugar levels are tested every 2 hours while that person is at their program. Update the ISP to reflect any new medical condition.
• Communicate with care coordinators of the MCOs to update them on an individual's needs and services and obtain results of their HRAs
• Collaborate with care coordinators regarding medical issues to develop coordinated plans to mitigate risks
• Report alleged abuse, neglect, or exploitation to adult protective services (APS) and child protective services (CPS).

Monitoring

• Review provider PCRs and other documentation to obtain input on medical information, appointment information, and to ensure that all needed follow-up has been done for all medical conditions and concerns.
• Obtain input from the person using services and the authorized representative or legal guardian, as appropriate, on satisfaction with all services and providers.
• Follow through with service providers regarding implementation of physician's orders, etc.
• Obtain information on all medications a person takes and include side effect information.
• Document medication changes and communicate information to all providers.
• Review CHRIS case management reports and provider incident reports for injuries and medical concerns, and document communication with providers to ensure that all needed follow-up occurred.
• Request needed medical records from family members, group home providers, and medical providers.
• Ensure that an individual obtains a physical within 12 months prior to enrollment into a DD Waiver.
• Update PC ISP as appropriate.

1. 5.24 91 Advocacy

• Advocate for annual physicals, dental exams, and other recommended preventive screenings and immunizations based on medical history, age, and gender.
• Advocate for needed referrals. Example: Someone has been having increased seizure activity. The primary care physician has not ordered any blood work, medical tests, or shown any concern about this increased seizure activity. The SC can advocate for a referral to a specialist, such as a neurologist, for more specialized care.
• Link to needed funding sources to cover someone’s needs. Example: Drug companies frequently offer reduced rate medications programs for those unable to pay for their prescriptions.

Optimal Health Maintenance of optimal health is one of the most basic supports provided by the team supporting a person with a disability. This is a shared responsibility among all entities who work with the person. It is a primary responsibility of the SC to lead the team in identifying health and safety risk factors, develop individualized supports, and to monitor the implementation of those supports and the person’s wellbeing. The level of active involvement with health care practitioners depends on the risk factors of each person.

Achievement of OPTIMAL HEALTH is based upon these principles:

• Person-Centered: People participate in decisions about their health and are supported in making person
• centered decisions about healthy lifestyles, such as food choices and activity.
• Access: People have adequate contact with health practitioners regarding their physical and mental health, receiving preventative health care and services, including recommended physical and dental exams, and timely assessment, treatment, and follow-up for acute and chronic health issues.
• Support: People are supported, as needed, in all aspects of their health care including decision-making, access, and following their prescribed treatment plans (e.g., medications, diets, mealtime instructions).
• Documentation: People’s health-related information, both current and historical, is documented accurately and available when needed. People have some form of identification, which includes emergency contact information, with them at all times.

PROACTIVE STEPS TO HEALTH Regular Medical and Dental Care Regular medical and dental care is crucial in helping people enjoy a healthy life. It is important for team members to work closely with each person’s primary care physician and other medical and health professionals to make sure regular routine tests and screenings are completed and to assist in communicating to the health professional issues someone might be experiencing. All team members should be on the lookout for changes in appearance or behavior that may indicate some symptom of illness. Some people may not be

able to fully communicate what they are feeling (physically and emotionally). It is important to be diligent in observing, monitoring, and reporting any of these changes. This role is usually done by the direct support professional ( DSP) as they, are likely to have the consistency of contact needed to be aware of and note changes. It is the role of the SC to monitor changes in health and safety and to work with the person and the

team

to

adjust

1. 5.24 92 supports accordingly.

Medication and Side Effects Some people take multiple daily medications. All medications can have side effects - some of which can be harmful. Side effects may indicate that the medication dosage or type may need to change. In addition, people on more than one medication may experience symptoms related to the interactions of their medications.

While it is impossible to remember all the possible side effects for medications, it is important that the SC know where to find this information. Reputable sites that include information about drugs, dosage, uses and side effects are listed in Chapter 11.

Barriers to Quality Healthcare Barriers to Quality Healthcare for People with Disabilities

• Difficulties communicating signs and symptoms to a health care provider about treatable yet untreated health conditions;
• Attitudes and assumptions of medical staff including discrimination and lack of empathy or caring for people with disabilities;
• Untreated specific health issues related to the person’s disability due to health care providers’
• inadequate knowledge;
• Decreased access to generic/preventive health screening as well as to specialists’ services
• Lack of independent mobility causing reliance on others to attend appointments;
• Behavior problems that may manifest themselves out of untreated medical conditions, fear, or disorientation; and
• Lack of time and resources.

Resource: Barriers in health care for people with disabilities: It’s not what you think.

Eight Health Risks The following is a list of areas in which changes may indicate signs of illness or a change in health status. There are eight health issues that are often overlooked and need to be more carefully monitored. These conditions can progress rapidly and result in bigger problems, even death. They are most likely to be identified and addressed by the DSPs who have regular contact with the person. However, the SC needs to be aware of the signs and symptoms of these health issues as well, so that they can properly monitor these conditions. The DBHDS OIH issues safety alerts on these conditions and provides a monthly newsletter that addresses health and safety issues. The eight health risks include: Skin Care (general) Healthy skin aids in regulating body temperature, protecting internal organs from injury and environmental elements, and protecting against infection.

7.5.24 93 Things to look for, but not limited to, and/or reports of:

• unusual or abnormal color (pale, pink, red, or bluish)
• rashes, cuts, open sores, raised bumps, blisters, bruises
• changes in skin temperature (such as moist, hot, or cool to the touch) and
• Parasites.

Decubitus ulcers/ pressure ulcers (bedsores) Decubitus ulcers are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. People most at risk of bedsores are those with a medical condition that limits their ability to change positions or those who spend most of their time in a bed or chair.

Bedsores can develop quickly. Most sores heal with treatment, but some never heal completely. Most pressure sores are preventable with the proper supports such as regular changes in positioning, different seating, and use of adaptive equipment. When pressure sores are a risk, physician orders for positioning protocols need to be developed and implemented. Documentation should be maintained on positioning logs that can be monitored by SCs. Skin integrity training is routinely offered by OIH.

Things to look for include:

• Unusual changes in skin color or texture;
• Swelling;
• Pus-like draining;
• An area of skin that feels cooler or warmer to the touch than other areas;
• Tender areas; and If there are signs of infection, such as a fever, drainage from a sore, a sore that smells bad, or increased redness, warmth or swelling around a sore, immediate medical attention should be sought, visit the Mayo Clinic website for more information.

Aspiration Pneumonia Aspiration pneumonia is an inflammation of the lungs and airways to the lungs from breathing in foreign material. Aspiration pneumonia develops from inhaling food, vomit, liquids, or saliva into the lungs. This may occur when someone has difficulty swallowing (dysphagia) and has watery eyes or coughing while consuming food or fluids.

Things to look for, but not limited to, and/or reports of:

• Chest pain
• Cough
• Fatigue
• Nausea
• Fever
• Shortness of breath, wheezing, and
• Bluish discoloration of the skin caused by lack of oxygen (e.g., mouth, nail beds, finger tips).

1. 5.24 94 Falls Fall risk is important to address as 1 in 3 older adults fall daily. Fall complications can include broken bones, head injuries, problem with daily activities, and need for home health care.

Things to look for, but not limited to, and/or reports of:

• Health issues and medication;
• Being shoved or running into a barrier;
• Cluttered rooms, area rugs, wet or slick surfaces, improper lighting;
• Wet or slick surfaces without non-skid footwear; and
• Lack of appropriate medical adaptive equipment or inappropriate footwear.

Urinary Tract Infections (UTI) A UTI is an infection of the urinary tract, which is the body’s system for removing wastes and extra water.

Women are more susceptible than men due to their anatomy and reduced bladder function later in life, and symptoms vary by age and gender. People who use wheelchairs or have reduced mobility are also more susceptible to developing UTIs. There are two different types of UTIs: the lower UTI relates to infections that occur in the urethra (a short narrow tube that carries urine from the bladder out of the body) and bladder, and the upper UTI is more severe and relates to infections that may involve the kidneys.

Things to look for, but not limited to, and/or reports of:

• Pain or burning during urination
• Increased frequency, urgency of urination, incontinence
• Lower abdominal, pelvic or rectal pain or pressure
• Confusion, behavioral changes, increased falls
• Mild fever or “just not feeling well” and
• Changes in urine (such as milky, cloudy, bloody or foul-smelling).

Upper UTI symptoms develop rapidly and may not include the symptoms for a lower UTI and require emergency care.

Things to look for, but not limited to, and/or reports of:

• Fairly high fever (higher than 101F)
• Shaking chills
• Nausea
• Vomiting; and
• Flank pain (pain in the back or side, usually only on one side at waist level).

Dehydration Dehydration occurs when we lose more fluids than we are taking in. The lack of water in the body may result from either a decrease in fluid intake or an increase in fluid loss. Water helps transport waste, supports tissue

1. 5.24 95 and cell hydration and helps regulate your temperature. Dehydration can be an important factor in illness and even death. Diarrhea and vomiting are the most common reasons why someone loses excess fluid.

Things to look for, but not limited to, and/or reports of:

• Urine is concentrated and more yellow
• Dry mouth and nose
• Dry skin
• Decreased tear production
• Headache
• Dizziness
• Sleepy or tired and
• Lightheaded (especially when standing).

SEVERE dehydration symptoms can include, but are not limited to confusion, lack of sweating, little or no urination, weakness, coma, organ failure (especially kidney), changes in vital signs (increase in pulse and decrease in blood pressure), and “tenting” of skin (sticks together, stays upright when pinched together).

Constipation and Bowel Obstruction Constipation is the slow movement of feces through the intestine which results in infrequent bowel movements and hard, dry stools. The longer it takes for stool to move through the large intestines, the more fluid is absorbed and the harder stool becomes, making it difficult and sometimes impossible to pass.

Things to look for, but not limited to, and/or reports of:

• Changes in bowel habits;
• Infrequent bowel movements (less than 3 a week or more than 3 days between);
• Difficulty passing stools - straining, painful;
• Hard, dry, lumpy, small stools;
• Belly pain relieved by bowel movements, swollen abdomen;
• Bright red blood in stools; and
• Leaks of wet, diarrhea-like stool between regular bowel movements.

Severe constipation can result in serious complications including rectal bleeding, nausea, vomiting, weight loss, bowel obstruction, fecal impaction, hemorrhoids, anal fissures and rectal prolapse. Two serious constipation issues are fecal impaction and bowel obstruction. Fecal impaction is when hard, dry stool is in the large intestines, often the rectum, and cannot be passed. Individuals with fecal impactions often have breathing difficulties due to the collection of the stool in the colon. Fecal impaction can be life-threatening. A bowel obstruction is either a partial or complete blockage of the small or large intestines and requires immediate medical attention! People who use wheelchairs and/or have reduced mobility are also more susceptible to developing a bowel obstruction. Use of a log to track bowel movements may be recommended to ensure people are having regular and adequate bowel movements. This log would typically be maintained by DSPs and can be monitored by SCs.

1. 5.24 96

Bowel obstruction: Things to look for, but not limited to, and/or reports of:

• Abdominal pain
• Swelling and fullness
• Vomiting
• Diarrhea, and
• Odor to breath.

Sepsis Sepsis is a serious medical condition caused by an overwhelming immune response to infection. Sepsis can arise unpredictably and can progress rapidly. Sepsis springs from two factors: an infection (such as pneumonia or a urinary tract infection) and a powerful and harmful response by the body’s own immune system.

In severe cases, one or more organs fail. In the worst cases, blood pressure drops, the heart weakens and the patient spirals towards septic shock. Once that happens, multiple organs - lungs, kidneys, liver - may quickly fail and the person can die.

Seizures Seizures are defined as abnormal movements or behavior due to electrical activity in the brain. Seizures might include shaking and convulsions, and can last a few seconds or over 5 minutes. Seizures have many causes and can lead to brain damage or even death. Diagnosis occurs when a person has had two or more seizures.

Providers should track and report seizures. SCs should routinely monitor seizure activity. There are many types of seizures.

Things to look for include, but not limited to, and/or reports of:

• Brief blackout followed by a period of confusion;
• Changes in behavior;
• Drooling or frothing at the mouth;
• Eye movements;
• Shaking of the entire body;
• Grunting or snorting;
• Loss of bladder or bowel control;
• Sudden falling;
• Teeth clenching;
• Tasting a bitter or metallic flavor;
• Temporary stop in breathing;
• Uncontrollable muscle spasms with twitching and jerking limbs; and
• Mood changes such as sudden anger, unexplainable fear, paranoia, joy, or laughter.

Medical Healthcare Professionals Healthcare professionals are broken out in the following chart for those that can assess and provide a care plan

1. 5.24 97 in their specialty addressing the prescribed treatment. Also consider utilizing other healthcare professionals for community supports to include, but are not limited to, DBHDS OIH Registered Nurse Care Consultant and the individual’s MCO care coordinator.

Type of Risk Healthcare Professional Who else can help?

Constipation Primary Care Practitioner Gastroenterology Specialist

Gastroesophageal reflux disease (Gerd) Primary Care Practitioner Gastroenterology Specialist Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Dietician

Occupational Therapist (OT)

Physical

Therapist

(PT)

Aspiration Pneumonia Primary Care Practitioner Gastroenterology Specialist Ear, Nose, Throat (ENT) Specialist Registered Nurse (RN) Licensed Practical Nurse (LPN) Speech Therapist (SLP)

Occupational Therapist (OT)

Seizures Primary Care Practitioner Neurologist Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Dehydration Primary Care Practitioner Urologist DBHDS: Office of Integrated Health RNCC MCO Care Coordinator Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Speech Therapist (SLP)

Occupational Therapist (OT)

Dietician

Behavioral Specialist

Urinary Tract Infection Primary Care Practitioner (PCP) Urologist Nephrologist Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Occupational Therapist (OT)

Dietician

Behavioral Specialist

Change in Mental Status Primary Care Physician (PCP) Neurologist Registered Nurse (RN)

Licensed

Practical

Nurse

(LPN)

1. 5.24 Registered Nurse (RN) Licensed Practical Nurse (LPN) Dietician Behavior Specialist Licensed Behavior Analyst Licensed Assistant Behavior Analyst Licensed Behavior Analyst Licensed Assistant Behavior Analyst Licensed Behavior Analyst Licensed Assistant Behavior Analyst Licensed Behavior Analyst 98 Psychiatrist Psychologist (cannot prescribe medication) Behavioral Specialist Counselor / Social Worker

Certified Therapeutic Recreation Specialist (CTRS)

Pressure Ulcers and/or Decubitus Ulcers Primary Care Practitioner (PCP) Orthopedist Endocrinologist (if individual has Diabetes) Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Occupational Therapist (OT)

Physical Therapist (PT)

Sepsis Primary Care Practitioner (PCP) Infection Disease Specialist (Emergency Room) Registered Nurse (RN)

Licensed Practical Nurse (LPC)

Diabetes Primary Care Practitioner (PCP) Endocrinologist Registered Nurse (RN)

Licensed Practical Nurse (LPC)

Dietician

Stroke Primary Care Practitioner (PCP) Neurologist Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Occupational Therapist (OT)

Physical Therapist (PT)

Speech Therapist (SLP)

Certified Therapeutic Recreation Therapist (CTRS)

Falls Primary Care Practitioner (PCP) Orthopedist Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Physical Therapist (PT)

Occupational Therapist (OT)

Congestive Heart Failure Primary Care Practitioner (PCP) Cardiologist Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Cellulitis Primary Care Practitioner (PCP) Infection Control Specialist Dermatologist (Emergency Room) Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Elopement /Wandering Primary Care Practitioner (PCP) Psychiatrist Psychologist (cannot prescribed medication) Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Behavior Specialist

1. 5.24 Licensed Assistant Behavior Analyst Licensed Assistant Behavior Analyst Licensed Behavior Analyst 99

Pain Primary Care Practitioner (PCP) Pain Management Specialist Medical Specialist for the area of the body where the pain is located Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Substance Abuse Related Primary Care Practitioner (PCP) Psychiatrist Psychologist (cannot prescribed medication) Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Substance Abuse Counselor

Counselor / Social Worker

Abuse, Neglect and Exploitation It is estimated that people with disabilities are between two and five times more likely to be victims of abuse as those without disabilities (Martin et al., 2006; Mitra, Mouradian, & Diamond, 2011; Plummer & Findley, 2011). Further, research has indicated that most abuse perpetrators are known by the person with DD and often include parents, intimate partners, extended family members, caregivers, teachers, bus drivers, and other paid service providers (Stevens, 2012). People with disabilities are also at greater risk of experiencing domestic and sexual abuse by non-intimate partners, including other family members and care providers within and outside of

institutions (Chenoweth, 1996; Oktay & Tompkins, 2004; Saxton, et

al., 2001;

Young, et

al ., 1997).

With these statistics in mind, the chances are great that an SC will support someone who is experiencing or has experienced abuse, neglect, or exploitation. The SC is required to report abuse, neglect, or exploitation in accordance with the Human Rights regulations and has additional reporting requirements as a “mandated reporter” as defined in Title 63.2 of the Code of Virginia.

The definitions for abuse (includes exploitation) and neglect as outlined in the Code of Virginia for the behavioral health and developmental services system in Title 37.2 of the Code of Virginia are:

• "Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the Department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to an individual receiving care or treatment for mental illness, developmental disabilities, or substance abuse. Examples of abuse include acts such as:

1. Rape, sexual assault, or other criminal sexual behavior;
2. Assault or battery;
3. Use of language that demeans, threatens, intimidates, or humiliates the individual;
4. Misuse or misappropriation of the individual's assets, goods, or property;
5. Use of excessive force when placing an individual in physical or mechanical restraint;
6. 5.24

• "Abuse" means the willful infliction of physical pain, injury or mental anguish or unreasonable confinement of an adult as defined in § 63.2-1603 of the Code of Virginia.
• “Adult” means any person 60 years of age or older, or any person 18 years of age or older who is incapacitated and who resides in the Commonwealth as defined in § 63.2-1603 of the Code of Virginia.
• “Neglect" means that an adult as defined in § 63.2-1603 is living under such circumstances that he is not able to provide for himself or is not being provided such services as are necessary to maintain his physical and mental health and that the failure to receive such necessary services impairs or threatens to impair his well-being. However, no adult shall be considered neglected solely on the basis that such adult is receiving religious nonmedical treatment or religious nonmedical nursing care in lieu of medical care, provided that such treatment or care is performed in good faith and in accordance with the religious practices of the adult and there is written or oral expression of consent by that adult. Neglect includes the failure of a caregiver or another responsible person to provide for basic needs to maintain the adult's physical and mental health and well-being, and it includes the adult's neglect of self. Neglect includes:

1. Use of physical or mechanical restraints on an individual that is not in compliance with federal and state laws, regulations, and policies, professionally accepted standards of practice, or his individualized services plan; and
2. Use of more restrictive or intensive services or denial of services to punish an individual or that is not consistent with his individualized services plan.as defined in the Code of Virginia.

• “Adult” means a person 18 years of age or more § 1-203 of the Code of Virginia.
• “Neglect" means failure by a person or a program or facility operated, licensed, or funded by the Department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, developmental disabilities, or substance abuse.

In addition to Title 37.2, the laws and regulations for the social services system in Title 63.2 regarding abuse, neglect, and exploitation are relevant:

1. the lack of clothing considered necessary to protect a person's health
2. the lack of food necessary to prevent physical injury or to maintain life, including failure to receive appropriate food for adults with conditions requiring special diets
3. shelter that is not structurally safe; has rodents or other infestations which may result in serious health problems; or does not have a safe and accessible water supply, safe heat source or sewage disposal. Adequate shelter for an adult will depend on the impairments of an adult; however, the adult must be protected from the elements that would seriously endanger his health (e.g., rain, cold or heat) and could result in serious illness or debilitating conditions
4. inadequate supervision by a paid or unpaid caregiver who provides the supervision necessary to protect the safety and well-being of an adult in his care
5. the failure of persons who are responsible for caregiving to seek needed medical care or to follow medically prescribed treatment for an adult, or the adult has failed to obtain such care for himself. The needed medical care is believed to be of such a nature as to result in physical or mental injury or illness if it is not provided
6. 5.24 100

Medical neglect includes the withholding of medication or aids needed by the adult such as dentures, eyeglasses, hearing aids, walker, etc. It also includes the unauthorized administration of prescription drugs, over-medicating or under- medicating, and the administration of drugs for other than bona fide medical reasons, as determined by a licensed health care professional, and

Self-neglect by an adult who is not meeting his own basic needs due to mental or physical impairments. Basic needs refer to such things as food, clothing, shelter, health or medical care.

• “Exploitation" means the illegal, unauthorized, improper, or fraudulent use of an adult as defined in § 63.2- 1603 of the Code of Virginia or the adult’s funds, property, benefits, resources, or other assets for another's profit, benefit, or advantage, including a caregiver or person serving in a fiduciary capacity, or that deprives the adult of his rightful use of or access to such funds, property, benefits, resources, or other assets. "Adult exploitation" includes:
• an intentional breach of a fiduciary obligation to an adult to his detriment or an intentional failure to use the financial resources of an adult in a manner that results in neglect of such adult
• the acquisition, possession, or control of an adult's financial resources or property through the use of undue influence, coercion, or duress, and
• forcing or coercing an adult to pay for goods or services or perform services against his will for another's profit, benefit, or advantage if the adult did not agree, or was tricked, misled, or defrauded into agreeing, to pay for such goods or services or perform such services.

Signs of abuse, neglect and exploitation

1. 5.24 101 The Code of Virginia states that mandated reporters who may have reason to suspect a child or disabled adult is being abused or neglected should immediately report to the local DSS. SCs are considered mandated reporters and are required to report all suspicions of abuse, neglect, and exploitation to APS, if the person is an adult. If the person is under 18 years or up to 21 years old while in the care of a legal guardian, CPS should be notified. For DBHDS-licensed providers, the offices of Human Rights and Licensing, as well as the Commonwealth Coordinated Care managed care organizations (MCO), if applicable for Medicaid recipients, must also be notified.

Department of Social Services/Child Protective Services (CPS) The DSS operates a CPS Hotline 24/7 to support local DSS offices by receiving reports of child abuse and neglect and referring callers to the appropriate LDSS. The CPS Hotline is staffed by trained protective services hotline specialists.

Department of Aging and Rehabilitative Services (DARS) & Adult Protective Services (APS) To report suspected abuse, neglect, or exploitation of adults 60 years of age or older and incapacitated adults ages 18 or older, call the local DSS office or the 24-hour, toll-free APS hotline. If protective services are needed and accepted by the individual, local APS workers may arrange for a wide variety of health, housing, social, and legal services to stop the mistreatment or prevent further mistreatment.

To access a list of mandated reporters visit Code of Virginia § 63.2-1606.

Reporting Abuse and Neglect: SC Responsibilities

• Immediately notify the local DSS if abuse, neglect, or exploitation is suspected.
• Be aware of the agency’s policy on reporting and (supervisor) notification, and follow CSB/BHA internal protocols regarding reporting abuse and neglect.
• The Virginia DSS 24-hour, toll-free APS hotline at: (888) 832-3858
• The Virginia DSS 24-hour, toll-free CPS hotline at (800)552-7096.

Notify the DBHDS Office of Human Rights and Office of Licensing in addition to LDSS if there is suspicion of abuse, neglect, or exploitation from a licensed DD Waiver provider in accordance with agency policies and state requirements.

Office of Licensing/Serious Incident Reporting The Office of Licensing oversees the serious incident reporting side of the Computerized Human Rights Information System (CHRIS). A serious incident means any event or circumstance that causes or could cause harm to the health, safety, or well-being of a person using services. As defined in the Licensing Regulations, the term “serious incident” includes death and serious injury. SCs should refer to agency policy and CHRIS roles for further guidance.

Mandated Reporting

1. 5.24 102 More information on serious incident reporting can be found in the licensing regulations and on the VA Department of Behavioral Health and Developmental Services website.

Computerized Human Rights Information System (CHRIS): SC responsibilities When a provider has identified and entered a serious injury, incident or death into CHRIS:

• Follow up with the provider to monitor the corrective action plan;
• Communicate with the individual and the authorized representative in order to determine ongoing satisfaction with the provider; and
• Document ongoing monitoring and follow up as it relates to the incident.

Office of Licensing – CHRIS Serious Incident Reporting The Office of Licensing oversees the serious incident reporting side of the Computerized Human Rights Information System (CHRIS). Licensing regulation 12VAC35-105-160 (D2) states that all serious incidents, including death, should be reported in writing to the DBHDS Office of Licensing within 24 hours. A serious incident means any event or circumstance that causes or could cause harm to the health, safety, or well-being of a person using services. The term serious incident includes death and serious injury. There are three levels of serious incidents.

Level I serious incidents do not result in significant harm to individuals, but may include events that result in minor injuries that do not require medical attention or events that have the potential to cause serious injury, even when no injury occurs. * Does not require reporting* Level II:

A serious injury;

An individual who is or was missing

An emergency room visit

An unplanned psychiatric or unplanned medical hospital admission of an individual receiving services other than licensed emergency services

Choking incidents that require direct physical intervention by another person;

Ingestion of any hazardous material

A diagnosis of: a.

A decubitus ulcer or an increase in severity of level of previously diagnosed decubitus ulcer; b.

Bowel Obstruction or;

Level III serious incident means a serious incident whether or not the incident occurs while in the provision of a service or on the provider’s premises and results in:

1. Any death of an individual
2. Any sexual assault of an individual
3. A suicide attempt by an individual admitted for services, other than licensed emergency services, that results in a hospital admission.
4. 5.24 103 c.

Aspiration Pneumonia Each CSB will have one or more staff identified as users who have capability enter information and to run reports to view allegations and complaints, and a summary of provider reports for individuals who receive support coordination from the

CSB.

When a provider has entered a serious injury, incident or death into CHRIS, SC should:

• Follow up with the provider in order to monitor the plan of corrective action plan;
• Communicate with the individual and/or the family/guardian in order to determine ongoing satisfaction with the provider; and
• Document ongoing monitoring and follow up as it relates to the incident.

Office of Human Rights Allegations/Abuse, Neglect and Exploitation Office of Human Rights The DBHDS Office of Human Rights (OHR), established in 1978, has as its basis the Regulations to Assure the Rights of Individuals Receiving Services from Providers Licensed, Funded, or Operated by DBHDS (the “ Human Rights Regulations”) [12VAC35-115]. The Human Rights Regulations outline DBHDS’ responsibility for assuring the protection of the rights of individuals in facilities and programs operated funded and licensed by DBHDS.

Title 37.2-400, Code of Virginia (1950), as amended, and the Office of Human Rights assure that each individual has the right to:

• Retain his legal rights as provided by state and federal law;
• Receive prompt evaluation and treatment or training about which he is informed insofar as he is capable of understanding;
• Be treated with dignity as a human being and be free from abuse or neglect;
• Not be the subject of experimental or investigational research without his prior written and informed consent or that of his legally authorized representative;
• Be afforded an opportunity to have access to consultation with a private physician at his own expense and, in the case of hazardous treatment or irreversible surgical procedures, have, upon request, an impartial review prior to implementation, except in case of emergency procedures required for the preservation of his health;
• Be treated under the least restrictive conditions consistent with his condition and not be subjected to unnecessary physical restraint and isolation;
• Be allowed to send and receive sealed letter mail;
• Have access to his medical and clinical treatment, training, or habilitation records and be assured of their confidentiality but, notwithstanding other provisions of law, this right shall be limited to access consistent with his condition and sound therapeutic treatment;
• Have the right to an impartial review of violations of the rights assured under this section and the right of access to legal counsel;
• Be afforded appropriate opportunities, consistent with the individual's capabilities and capacity, to participate in the development and implementation of his individualized services plan; and

1. 5.24 104

• Be afforded the opportunity to have a person of his choice notified of his general condition, location, and transfer to another facility.

OHR advocates represent individuals receiving services from providers of mental health, developmental disabilities, or substance abuse services in Virginia whose rights are alleged to have been violated and perform other duties for the purpose of preventing rights violations. Each state facility has at least one advocate assigned, with regional advocates located throughout the state who provide a similar function for individuals receiving community services. Their duties include investigating complaints, examining conditions that impact individuals’ human rights, and monitoring compliance with the Human Rights Regulations. At times, an individual receiving services or anyone acting on the individual’s behalf may request to be linked with the regional human rights advocate.

Local human rights committees (LHRCs) are comprised of community volunteers who are broadly representative of various interests of individuals receiving services and professionals in the system. LHRCs play a vital role in DBHDS’ human rights structure, serving as an external component of the human rights system. LHRCs review individuals’ complaints not resolved at the program level; review and make recommendations concerning variances to the regulations; review program policies, procedures, and practices; make recommendations for change; conduct investigations; and review restrictive programming.

Office of Human Rights: SC responsibilities If a person requests to be linked with their OHR advocate the SC must:

• Provide the contact information for the advocate;
• Reach out to the advocate on behalf of the individual; and
• Document the person’s request and the action taken.
• Statewide listing of OHR staff

1. 5.24 105 Caregiver Stress and Burnout As a Support Coordinator providing in-home visits, it is important to recognize the emotional, physical, mental and financial demands of being a caregiver. Some caregivers are well connected, while others may be isolated, and you may be one of the few people who visit the home. While you are there to support the individual, be attentive to the caregiver(s). Listen for requests they make for additional supports as well as comments about their lack of sleep or their own health (physical or mental) problems or their additional financial burdens. If possible, assess other responsibilities the caregiver may have. Don’t be afraid to ask about their own support system. Offer information for resources that are available in their community. Be proactive. If you believe supports are needed sooner than later, don’t hesitate to escalate those concerns to your supervisor.

Caregivers commonly experience high levels of stress, anxiety, depression and other mental health effects.

Read more at the Family Caregiver Alliance (https://www.caregiver.org/resource/caregiver-health/).

Signs of caregiver stress and burnout are listed below.

Signs of caregiver stress

• Feeling overwhelmed or constantly worried;
• Feeling tired often;
• Getting too much sleep or not enough sleep;
• Gaining or losing weight;
• Becoming easily irritated or angry;
• Losing interest in activities once enjoyable;
• Feeling sad;
• Having frequent headaches, body pain, or other physical problems; and
• Abusing alcohol or drugs, including prescription medications (https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/caregiver-stress/art-20044784) Signs of caregiver burnout
• Withdrawal from friends, family, and other loved ones;
• Loss of interest in activities previously enjoyed;
• Feeling blue, irritable, hopeless and helpless;
• Changes in appetite, weight, or both;
• Changes in sleep patterns;
• Getting sick more often;
• Feelings of wanting to hurt oneself or the person being cared for;
• Emotional and physical exhaustion; and
• Irritability (https://my.clevelandclinic.org/health/diseases/9225-caregiver-burnout)

1. 5.24 106 Caregiver stress and/or caregiver burnout can lead to a mental health crisis. Warning signs include having trouble with daily tasks, sudden, extreme changes in mood, increased agitation, abusive behavior, isolation, paranoia and symptoms of psychosis. Warning signs are not always present when a mental health crisis is developing. Be attentive to these warning signs of suicide:

• Giving away personal possessions;
• Talking as if saying goodbye;
• Taking steps;
• Making or changing a will;
• Collecting and saving pills or buying a weapon;
• Saying things like “Nothing matters anymore;”
• Withdrawing from friends, family, and normal activities; and
• Increasing drug or alcohol use.

Emotional support can help to deal with the stress of caring for someone with a disability. The impact on the caregiver cannot be minimized. Caregivers experience elevated levels of depression and anxiety, higher use of psychoactive medications, worse self-reported physical health, compromised immune function and increased risk of early death https://www.cdc.gov/aging/caregiving/index.htm.

Signs of Abuse and Neglect as a Result of Caregiver Burnout

• Injuries of unknown origin;
• More restrictive supports in the home;
• Less restrictive supports in the home;
• Reports by the individual of use of: o Intimidation o Humiliating or aggressive language;
• Failure to protect from harm; and
• Failure to meet essential needs to include: o Essential medical care o Nutrition o Hydration o Hygiene o Basic activities of daily living or shelter.

In extreme cases, suicide and filicide (the killing of one’s son or daughter) are carried out. Read An Overview of Filicide (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2922347/) to learn more. If you have concerns with a caregivers’ level of stress or behavior, or fear for any family member in the home, please reach out to your supervisor for guidance. As a mandated reporter, you are required to report concerning suspicions. DSS has two 24-hour, toll-free hotlines (one for concerns about children and one for adults). The hotline staff are trained to provide crisis counseling and intervention if needed and can provide information and referral assistance to callers to locate prevention and/or treatment programs in their area as appropriate. The hotline numbers are provided under the DARS & APS section found earlier in this chapter.

1. 5.24 107 Connecting a caregiver to resources is the first step to providing support. Chapter 11 contains resources and information related to caregiver support.

End of Life It is inevitable that Support Coordinators will experience the death of someone they are supporting. In some instances, the SC will have had a relationship with this person for years and they will experience grief and sadness. It is important that the SC reach out and rely on their own support systems during these times of loss.

The relationship is a professional one, but also a human relationship, one with feelings, caring and regard. It is okay to acknowledge this and grieve. SCs may need to assist persons in obtaining end of life care through hospice or other medical providers.

Death and Serious Incidents When a person who uses SC services passes away, there are a number of steps the SC takes to document the event. Each CSB/BHA has internal procedures, so the SC should check with the supervisor to ensure all documentation requirements have been completed.

Licensing regulation 12VAC35-105-160 (D2) states that all serious incidents, including death, should be reported in writing to the DBHDS Office of Licensing within 24 hours. CHRIS is the state database system used to document serious incidents, such as death . Training is accessible via the following link under Advocate Information: https://dbhds.virginia.gov/quality-management/human-rights.

1. 5.24 108 Introduction In addition to the private providers who provide services and supports for individuals with developmental disabilities, the Support Coordinator (SC) relies on the supports and services of many organizations to help them carry out their job responsibilities. Below are just some of the resources.

DBHDS (804) 786-3921

• Division of Developmental Services https://dbhds.virginia.gov/developmental-services
• Waiver Services https://dbhds.virginia.gov/developmental-services/waiver-services
• Crisis Services - (REACH Adult DD Crisis Services, REACH Children DD Crisis Services, Statewide and Regional Resources/Documents) https://dbhds.virginia.gov/developmental-services/Crisis-services
• Community Integration and Transition Supports (Training Center Transition Services, Regional Support Teams, Guardianship, Family Resource Consulting, Single Point of Entry for ICF/IIDs, Incident Management/Quality assurance) https://dbhds.virginia.gov/developmental-services/icf-iid/
• Community Support Services (Employment, Housing, Individual Family Support Program) Employment https://dbhds.virginia.gov/developmental-services/employment
• Housing https://dbhds.virginia.gov/developmental-services/housing The IFSP is designed to assist those on the DD Waiver waitlist and their families to access short-term, person-and family- centered resources, supports, and services. These services and items funded through the IFSP are intended to support the continued residence of an individual in his own home, family home, or in the community. SCs can encourage families and individuals to apply for this funding and offer support, as needed, in the application process. More information can be found at the IFSP website: Individual and Family Support Program.

• US Department of Justice Settlement Agreement with Virginia.
• Home and Community Based Settings Regulations. (844) 603-9248
• My Life My Community: o Search for Providers o Virginia DD Waiver Guidance (select Navigating the DD Waivers Guidebook)
• Office of Integrated Health.
• Office of Human Rights.
• Office of Licensing
• Licensed Providers and Provider Inspection/Investigation Reports Search.

1. 5.24 Behavioral Services https://dbhds.virginia.gov/developmental-services/behavioral-services/

• 109 An alphabetical list of links for community resources follows: American Association on Intellectual and Developmental Disabilities (AAIDD) (202) 387-1968 The Arc of Virginia Centers for Independent Living Centers for Medicare & Medicaid Services Community Health Clinics Department for Aging and Rehabilitative Services Department of Education: Special Education Department of Health Department of Medical Assistance Services (804) 786-7933 (General Information), (800) 343-0634 (TTY) Department of Social Services (804) 726-7000 (General Information) disABILITY Law Center of Virginia (800) 552-3962 Disability Navigator Early Periodic Supports Diagnosis & Treatment (EPSDT) The Olmstead Initiative Parent Educational Advocacy Training Center Partnership for People with Disabilities/Virginia Commonwealth University (804) 828-3876 (Voice), (800) 828-1120 (TTY) Positive Behavioral Supports

1. 5.24 Virginia Association for Behavior Analysis www.virginiaaba.org

110 Social Security Administration Virginia 2-1-1 Virginia Association of Community Service Boards (804) 330-3141 Virginia Board for People with Disabilities Virginia Navigator Virginia Parks & Recreation Caregiver Stress Support My Life My Community Website https://www.mylifemycommunityvirginia.org Disability & Health Information for Family Caregivers https://www.cdc.gov/ncbddd/disabilityandhealth/family.html Partnership for People with Disabilities – Center for Family Involvement https://partnership.vcu.edu/programs/community-living/center-for-family-involvement/Suicide Prevention: 1-800-273-8255 and website: https://suicidepreventionlifeline.org/Child Abuse/Neglect hotline (Virginia): 1-800-552-7096 Adult Protective Services hotline (Virginia): 1-888-832-3858 DARS APS Division: https://www.vadars.org/aps/Virginia Department of Social Services: https://www.dss.virginia.gov/about/abuse.cgi Virginia COPES (Support through talking or texting about struggles and mental health; Spanish speaking counselors are available): 1-877-349-6428

1. 5.24 111 Family Violence and Sexual Assault Virginia Hotline: 1-800-838-8238 LGBTQ Partner Abuse and Sexual Assault Helpline: 1-866-356-6998 (Instant messaging and texting options available – for texting: 1-804-793-9999 National Domestic Violence Hotline: 1-800-7993-7233 National Alliance for Mental Illness (NAMI): 1-888-486-8264 National Alliance for Mental Illness (NAMI) Virginia Chapter: 1-804-285-8264
2. 5.24 112 Why Work?

We derive meaning and a sense of self from many things in our life including our family, our friends, and our work. Employment contributes much to the way we view ourselves. Employment can impact our sense of self in many positive ways especially when we find the right job with the right support. These simple truths are no different for a person with a disability.

Impacts of Employment Economics. Unlike the majority of the population, most people with developmental disabilities live at or near the national poverty level. Income from paying jobs can supplement resources and improve the quality of lives.

Relationships. Employment is where people develop relationships, friendships, and acquaintances with other people. Through work, people with developmental disabilities have more opportunities to become connected to the greater community. People with disabilities who are employed report having a higher number of friendships with people without disabilities than those who do not work.

Meaning. Our society values employment for all adults. Through employment, people with developmental disabilities gain skills, experience, and often a better understanding of the world around them. Being employed, in addition to the financial benefits, can make people feel there is a purpose to their lives.

Self Esteem. Employment can contribute to a sense of accomplishment, increasing one’s sense of competence and self-worth. People with developmental disabilities who work believe more in their abilities and develop higher expectations for what they can accomplish. This can spread to other areas of their lives.

Identity. Much of who we are and how we are perceived by others is related to our employment in where we work, what we do, and the connections we make. People with developmental disabilities can benefit in the same way from employment.

1. 5.24 113 Virginia’s Recognition of the Importance of Work Through a gubernatorial proclamation signed on October 4, 2011, Virginia joined a number of states that had declared themselves Employment First states.

The Association of People Supporting Employment First (APSE) defines "Employment First" as: Employment in the general workforce is the first and preferred outcome in the provision of publicly funded services for all working age citizens with disabilities, regardless of level of disability.

In its official statement on Employment First, APSE maintains the following:

• Access to “real jobs with real wages” is essential if citizens with disabilities are to avoid lives of poverty, dependence, and isolation;
• It is presumed that all working age adults and youths with disabilities can work in jobs fully integrated within the general workforce, in typical work settings, working side-by-side with people without disabilities, earning regular wages and benefits and being part of the economic mainstream of our society;
• It is presumed that individuals with disabilities are capable of working until proven otherwise, and employment in the general workforce is the first option pursued;
• As with all other individuals, employees with disabilities require assistance and support to ensure job success and should have access to those supports necessary to succeed in the workplace;
• All citizens, regardless of disability, have the right to pursue the full range of available employment opportunities, and to earn a living wage in a job of their choosing, based on their talents, skills, and interests; and
• Implementation of Employment First principles must be based on clear public policies and practices that ensure employment of citizens with disabilities within the general workforce is the priority for public funding and service delivery Ethical Standards and Guidelines from APSE that influence SC work :
• Everyone has employable strengths and can work in the competitive labor force with the right measure of support and in jobs well-matched and sometimes customized to their interests and abilities;
• People with disabilities are the experts about themselves and should play a leading role in decisions that affect their lives;
• Companies who hire people with disabilities will profit in many ways, including financially
• The focus of publicly funded services should be strengths-based - what people can do, not what they cannot do;
• An important role of the organization is to educate policymakers, including elected officials, on advocating for equal opportunities and fair treatment in the workplace.

1. 5.24 114 The case has already been made for employment for all based on economics, relationships, meaning, self-esteem, and identity. Who can argue the value of each of these aspects and how they improve one’s quality of life? Yet, according to the U.S Bureau of Labor Statistics, in 2020 only 17.9 percent of people ages 16 and older with a disability were employed. This is down from 19.3% in 2019 and contrasts with61.8 percent of people without a disability who were employed.

In Virginia, the concept of Employment First means offering the option of integrated, competitive employment as the first choice of day activity to people entering services. It means no longer asking whether a person can work, but instead asking what employment best matches the person’s strengths, skills, interests, and conditions for success.

Definition of Employment Employment means

• Working in a typical work setting where the employee with a disability works alongside coworkers without disabilities;
• Earning a competitive wage, i.e. minimum wage or better, along with related benefits; and
• Doing meaningful tasks that contribute to the organization or business, with an opportunity for career advancement.

Role of the Support Coordinator The role of the SC is multi-faceted. A SC needs to be able to wear a variety of hats in supporting a person achieve their employment goals. Below is a diagram illustrating the diversity of the SC’s role. Each facet of the wheel will be discussed along with how these activities translate into helping a person achieve meaningful employment.

1. 5.24 115 Assess A SC should begin by using active listening skills to discover how people they support view employment; whether they want to work; what their employment dreams and goals are; what interests, experiences, and skills they have that will lead the way to paid employment; and how they would be best supported in a working environment.

Often a person with DD will have no reference for choosing work. In order to appropriately assess this, the person who is being assessed has to understand what work is, what the benefits of work are, and what the possibilities of working can be. The provision and review of all the relevant information can help to ensure the person is making an informed choice. Examples of relevant information include such things as:

1. Potential opportunities to learn about work, the types of jobs people do, and exposure to working people within their interest areas;
2. The skill sets required by different jobs;
3. What the person may need to do to acquire those skills; and
4. Which supports the person may need on the job.

Information gathered from both the person who wants to work and the team who knows them well may come from asking the following types of questions:

1. From the personal profile, what is there that demonstrates a skill or talent that might be used in a work environment or would be valuable to a prospective employer? For example, does the person have a good memory? Is the person friendly. Is the person organized?
2. Has the person had experiences that could lead to paid work, sush as holding volunteer or paid jobs in the past? What did the person like or dislike in each of these experiences?
3. Does the person have specific career interests or places desired for a work setting? *(Word of caution: The ‘obvious’ isn’t always the best. An interest in animals does not mean that someone wants to work with them. Also, do not make the assumption that a first job will be the only job a person will ever hold. Just as employment is an exploratory process for most of us, it is the same for a person with a disability. Imagine working in a job with the expectation of keeping that same job until retirement.)
4. From the essential information, under Employment, a conversation regarding employment is expected. Discuss all of the following topics to include employment interests; available options; satisfaction or dissatisfaction with current services; barriers related to pursuing employment options; addressing barriers, as applicable; a timeline for reviewing options in the future (at least annually); any related actions that will be taken; what the person is working on at home and school that will lead to employment; and alternate sources of funding (such as school or

DARS).

1. Looking at “Important To and Important For” in the person-centered plan, is there anything that could help the person be successful in areas of interest or places where the person wants to work?
2. Does the person have behavioral support needs (either in the past or present) that are causing the person to be held to a higher standard around employment, in order to be given a chance to work, than others in the community? Should overcoming them be a requirement of
3. 5.24 116 becoming employed? Is this fair? Can some of these issues be addressed through the right job match?

A good resource for collecting information about interests, possible job avenues, best support, and involving people in writing their own resumes is the I Want to Work Workbook and Partner Guide.

Free copies may be obtained, as long as supplies last, from the Partnership for People with Disabilities at VCU (804-828-3876).

Link As a SC, linking a person with the right resources, including resources already present in their lives is another key element of success. While all efforts around work should focus on the person first, it is important to remember we all have support networks that help us to achieve our goals. Family, friends, professionals and advocates are often members of the “typical” team for a person with disabilities, yet the truth is the team can be comprised of anyone the person thinks can support them in achieving their employment goals. Part of getting the answers and helping the person achieve their goals is helping them to identify and leverage their personal networks. Many people find their first job and other jobs through people they know. This is no different for someone with a disability.

Therefore, understanding and knowing the people who comprise the person’s personal network can be critical to ensuring success. Success is equally dependent on linking personal networks with other professionals supporting the person in achieving their employment dreams. There can never be enough linking or educating about organizations that support people in working towards employment.

The SC can:

• Explore personal networks for employment resources and connect with professionals if needed;
• Connect the person to appropriate professional resources; o DARS; o Employment Service Organizations (ESOs); o Benefits Planning Services;
• Connect DARS and ESOs to people in the person’s network;
• Discuss educational and post-secondary educational opportunities to enhance skills for employment ; and
• Connect to community learning opportunities.

Assist Assisting people means supporting them to reach their goals. There are legitimate things that may have to occur in order for people to be successful in the job that they choose. Supporting persons in selecting among options based on the relevant information and then honoring individual choice is essential. Recognizing that the choices people make may be different from the choices other team members might make for them is fundamental to creating a respectful, supportive environment.

Identifying any barriers is critical, and equally important is developing a game plan to break down those barriers. All members of the person’s team are needed to address barriers. The team should not identify a barrier and simply determine it to be insurmountable. Moving from a mindset of “can’t” to “how” is imperative. Team members will need to be focused and creative in addressing issues around barriers that interfere with the choices a person has made, especially issues involving staffing and transportation. In this instance, the “more heads are better than one” adage could not be truer. The

1. 5.24 117 more minds there are trying to find solutions to overcome barriers, the better, as there will be more creativity involved.

It is the SC’s role to lead the team in creativity, ingenuity, and determination to problem-solve.

• Who is in the person’s personal network that can help work toward finding and keeping employment?
• Ask the question: What could we do NOW to help the person be employed in the future?

What are skills and talents that could be tapped into? o What activities are available in day support or community engagement that could expand their options and knowledge of work and career possibilities? o What are the obstacles? What could be done NOW to help overcome these obstacles? o Garner support from current providers to think outside the box and put something into place in the person’s current plan to address these obstacles.

Common Barriers Barriers to employment are unique to each person served but several barriers are common. These barriers include: Lack of funding. If someone does not have waiver services, paying for job development and support services for many families is impossible. DARS may be used as a resource, but often their resources are limited as well.

Misconceptions about benefits. Families may fear that employment will mean a loss of government benefits such as SSI and Medicaid.

Attitudes. Lack of belief that a person with DD can work may be present in families, employers, and even the person.

Lack of opportunity. This is true especially in rural areas where job opportunities for all people are limited.

Lack of transportation. Resource: Employment Programs for Persons with Developmental Disabilities- Department of Health and Human Services OFFICE OF INSPECTOR GENERAL August 1999.

Possible ways to address barriers:

• Explore local funding and new services;
• Consider natural supports;
• Use work incentives;
• Use ABLE accounts;
• Use the PASS plan;
• Educate job seekers and family members- show videos from www.realworkstories.org;
• Advertise with personal networks;

1. 5.24 118

• Look at small business and local companies;
• Consider ride share, community transportation; and
• Leverage family peer mentoring.

Building a Resume Anyone interested in working needs a resume. Throughout the process of assisting someone in securing employment, there are many activities a person can do to add to and build a resume.

While working on finding a paid job, meaningful, productive activities can help increase skills, knowledge, and experiences and also be fun. As with all employment-related pursuits, these should be based on the interests and preferences of the person being supported. Activities may include but are certainly not limited to:

• Volunteer work;
• Taking classes at technical school, community college, community adult education, and/or local cultural sites, such as museums or art studios;
• Taking online courses;
• Attending workshops, seminars, or conferences;
• Pursuing internships;
• Joining service or charitable organizations;
• Participating in charitable events;
• Attending camps that stress academics, teach skills, or show team-building;
• Joining advocacy organizations; and
• Developing hobbies that facilitate job-related skills.

All of these activities should be tracked and added to a resume.

Plan Recognizing that people know the most about their situations necessitates involving them in every decision. The person should be an active participant in developing the person-centered plan, including discussion of integrated, competitive employment services at least annually and inclusion of employment goals or goals that break down barriers to employment in an individualized support plan.

Remember “nothing about me without me!” How can this be done?

In thinking about a first job, imagine it to be the only job or employment to which one is tied until retirement. Many of the general population today would be working as camp counselors, fast food employees, grass cutters, or babysitters. With people with disabilities, we sometimes forget that a person’s first job is not necessarily meant to be the last job. In fact, the people we support should have the same opportunities to grow, learn, and change as the rest of the population.

The SC’s role is to help people they support identify what they want their future to look like. This is called career planning and it involves:

• Recognition that planning goes beyond getting the person a job, yet at the same time

1. 5.24 119 understanding and communicating with the job-seeker and family that most first jobs help people develop valuable work skills that may lead to advancement;

• Identifying what someone’s long-term career aspirations are and assisting in developing plans for two, five, or ten years into the future;
• Identifying what additional educational or training opportunities will help the person reach set goals.

Planning is also an opportunity to expand a person’s understanding of the importance of employment through conversations:

• Asking the person why he is working and explaining the importance of the tasks he is being asked to complete;
• Helping a person see where he fits in the organization and brainstorming opportunities for advancement that might exist; and
• Explaining the dignity of work, the value added to the organization through the tasks performed, and how a paycheck is earned.

It is important for the SC to talk with the person about how it is possible that advancement in a job may happen over time, but this may not be the case for everyone. Teaching the person how to grow in his current position, to master new skills, and to branch out to learn other areas, actually supports the person in becoming a more valuable and hopefully more satisfied employee.

Coordinate Coordination of services ensures that multiple people providing support are not working on the same things. Teams can move more quickly if they divide up responsibilities and have each member take a role in helping the person achieve employment goals. Having a coordinated plan will minimize confusion.

• Coordinate responsibilities o Who will be carrying out which duties? o Who will make necessary appointments with other professionals? o Who will accompany them to intake appointments? o Does the person need supports and services? Not all of the people SCs support do. o Is there funding available for services or supports? How can it be accessed? o Are the right supports available? Who will coordinate the involvement and implementation?
• What are transportation options open to the individual if they have a job? How are they accessed? How will they be paid for?
• Is there a provider that a referral could be made to now? If not, what information could be provided that would assist in the choice of provider at a later date?

Monitor Monitoring services will ensure that the person maintains the paid and unpaid supports and assistance that they need. The Support Coordinator’s role in monitoring is different depending on whether or not the person has a job and whether or not paid supports are in place. Monitoring when the person does

1. 5.24 120 not have a job means ensuring the team continues to identify and address barriers, while at the same time providing education and training around realistic expectations of the person and of potential employers. When the person has a job, monitoring ensures that the person still has the desired job, that the hours are compatible, and that he is happy with the job situation. This monitoring ensures that a person has an opportunity to share when or if he is unhappy in his work or would like to pursue another job.

Questions to Ask

• Is the person working? If no o Are the barriers that have been identified being addressed? This requires thinking “outside the box” in many instances. o Is the team job developing consistently? o Are they (the person and other team members) satisfied with the supports and services implemented towards securing employment? o Refer the person to experts who can provide counseling on benefits such as SSI, social security disability insurance (SSDI), Medicaid, and Medicare (see the box below under Misinformation about Employment and People with Disabilities for information about these experts).
• Is the person working? If yes o Is there satisfaction with the job? o Is it the job desired? o Do the hours work? o Are there any unmet employment needs? o Is the team actively involved, on the same page?

Supporting the person through training in self-advocacy and encouraging discussion with the job coach, supervisor, employer, or the employment service provider by role-playing to increase effective communication can help a person raise and address changes that are needed to ensure greater job satisfaction. It is also helpful for the SC and the rest of the support team to share with the person the fact that people aren't always completely happy in their jobs. It may be that a person cannot always be accommodated. However, there is a balance to be achieved between the perfect job and an awful job; that is a job that meets our most important needs, provides fair compensation, and engages us in meaningful work and gain skills for our next opportunity.

Follow-up Once the SC has assessed, linked, assisted, coordinated, and monitored, the next step in supporting a person in achieving goals is follow-up. The SC, with the assistance of the right people, work together to ensure the person’s dream is not forgotten.

• Are the barriers that have been identified being worked on? o Have alternatives been identified?
• Is the person job developing consistently? o If not, why not and how can this be resolved?
• Is the person satisfied with the supports and services implemented towards getting a job?

1. 5.24 121

• Who can help the person to become satisfied?
• Does the person still need the same level of supports and services?
• Does the person need assistance with managing their benefits?

Advocate SCs serve a critical role in advocating for the person including:

• When people are unintentionally hindered by others who are acting in what they believe is the person’s best interest;
• Dispelling myths and misconceptions, both positive and negative, about a person’s ability or lack of ability; and
• Creatively addressing barriers and concerns that are raised. The SC need not have all the answers but instead should know where to connect the person to get them. The SC should be the initiator of brainstorming efforts and steer clear of shutting down discussions that may be “outside the box.” SCs also play an important role in system transformation, as this can only occur when advocates come together, united to educate and change the system. Often SCs are leaders in this effort as they can do much to educate the community at-large through their day-to-day responsibilities. SCs:
• Educate families, individuals, and team members about the value of employment;
• Identify barriers to employment in communities;
• Leverage personal and professional networks and communicate the value of employing individuals with disabilities; and
• When needed, work with ESOs to overcome those barriers.

Transportation Resources As stated above, lack of transportation is a common barrier to obtaining and keeping employment. SCs can link those they support with a variety of options, granted that this may take some creativity. Some resources are: Personal Networks When looking for work, is it possible for the job seeker to find work within walking distance or at or near a business in which the person already knows someone? Explore networks in a person’s life for transportation resources. Family, friends, or privately-paid acquaintances may be transportation resources.

1. 5.24 122 “Carpooling” with a co-worker may be an option in which the non-driver contributes gas money in place of taking turns to drive. Also, private ride share companies could be used for occasional needs.

Public Transportation/Travel Training Many people get to their places of employment by using public transportation, such as buses and subways.

Travel training may be available to teach a variety of travel skills that will enable the person to use local transportation independently. Here are some of the available resources in Virginia, but the SC should continue to search for others on the internet.

The Arc: Northern Virginia ENDependent Center of Northern Virginia, Inc.

MetroReady Travel Training and System Orientation for People with Disabilities and Outreach Richmond metro Paratransit Paratransit is a specialized, door-to-door transport service for people with disabilities who are not able to ride fixed-route public transportation. Fact Sheet: Paratransit Services.

Employment and Community Transportation For people who use Waiver services, each of the three DD Waivers includes a service entitled employment and community transportation, which includes assistance with getting and going to a job. If someone has fee-for-service (FFS) Medicaid, MCO, or CCC+, the person may be eligible for non-emergency medical transportation (NEMT) services. This service will take a person to Medicaid-covered services such as medical and health care appointments, supported employment, and day support programs.

Parking placards and plates for people with disabilities The Virginia Department of Motor Vehicles (DMV) offers parking placards and plates for customers with temporary or permanent disabilities that limit or impair their mobility. They are also available to customers with a condition that creates a safety concern while walking (examples are Alzheimer's disease, blindness, or developmental amentia).

These placards and plates entitle the holder to park in special parking spaces reserved for individuals with disabilities. Institutions and organizations that operate special vehicles equipped to carry persons with disabilities may also obtain parking placards and plates entitling them to special parking privileges.

Parking Placards and Plates for Virginians with Disabilities.

Vehicle Modifications For those who use waiver services, environmental modifications are included on all three DD Waivers and may include reimbursement for changes to a personal vehicle. Vehicle Modifications.

1. 5.24 123 Misinformation about Employment and People with Disabilities There are assumptions about people with disabilities and employment, such as:

• Not everyone can work! Everyone should be given the opportunity to explore work. Even people with the most significant disabilities can and do work. https://www.thinkwork.org/project/real-work-stories
• You can’t work and keep benefits! SCs recognize that the person and the family may have real concerns about work, income, and its impact on benefits. It may have taken a longtime to be approved for benefits. They are concerned about losing benefits. Fear of losing cash benefits, and medical coverage under Medicaid (SSI) or Medicare (SSDI), often persuades individuals to severely limit their employment participation and earnings or, more commonly, not to enter the labor force at all. Unfortunately, beneficiaries are often told that employment will lead to the loss of their benefits.

Additional Information about Benefits

• Special rules make it possible for an individual with disabilities receiving SSI or SSDI to work and still receive monthly payments and Medicaid or Medicare. Social Security calls these rules “work incentives."
• If the person currently receives Medicaid, eligibility should continue for Medicaid even after SSI cash benefits stop due to work. Section 1619(b) of the Social Security Act provides some protection. To be eligible, certain requirements must be met, including earnings below a threshold amount set by Virginia. Even if earnings exceed the state threshold, the person may still be eligible under certain circumstances.
• If a person earns enough that SSDI checks stop, Medicare can continue for up to 93 months.
• Individuals do not need to reapply if their benefits have ended within the past five years due to their earnings and if they meet a few other requirements, including that they still have the original medical condition(s) or one related to it that prevents them from working. This is a work incentive called “expedited reinstatement."
• Social Security ordinarily reviews an individual’s medical condition from time to time to see whether they are still disabled, using a process called the medical continuing disability review, or medical CDR.

If the individual participates in the Ticket to Work program with either DARS or another employment network (EN) and makes “timely progress” following the individual work plan, Social Security will not conduct a review of the medical condition. If a medical CDR has already been scheduled before the ticket is assigned, Social Security will continue with the medical CDR.

• You only get one chance to work! Sometimes, a job comes along but it is the wrong job, the wrong time or, the wrong supervisor. People with disabilities are no different in this regard; sometimes it takes a couple of times to find the right job, at the right time, with the right people!
• People with disabilities can only do entry level work in the food, cleaning, and manufacturing industries! This is not true. People with disabilities in Virginia are working as advocates, data entry specialists, mechanics, hospital workers, etc. People are only limited by society’s perception of them.

1. 5.24 124

• MEDICAID WORKS is a work incentive opportunity offered by the Virginia Medicaid program for people with disabilities who are employed or who want to go to work. MEDICAID WORKS is a voluntary Medicaid plan option that will enable workers with disabilities to earn higher income and retain more in savings or resources than is usually allowed by Medicaid. This program provides the support ofcontinued health care coverage so that people can work, save and gain greater independence.

More information on Medicaid Works may be found at Medicaid Works (Medicaid Buy-In).

Employment Services under Waivers If an individual has one of the three DD Waivers, there are employment services offered. All three Waivers provide:

• Supported Employment, both individual and group; and
• Community Engagement - a service where employment skills can be built.

An additional employment service, Workplace Assistance, is also provided under the Community Living Waiver and the Family and Individual Support Waiver. Ordinarily

DARS

would

be

a

first

option

for

referral

for

employment

services

for

people

who

use

Waiver

services.

However,

this

may

be

bypassed

when

DARS

has

a

waitlist.

Acceptable

documentation

for

this

would

be: 1) Written

documentation

from

DARS

or

the

school

system,

OR 2) Progress

note

that

records

the

content

of

a

communication

that

includes

a

name,

date, and

person

contacted,

documented

either

in

the

individual’s

file

maintained

by

the

SC on

the

ISP

or

the

supported

employment

provider’s

supporting

documentation.

Unless

the

individual’s

circumstances

change

(for

example,

the

individual

is

seeking

a

new

job),

the

original

verification

.

If

an

individual

is

eligible

for

Vocational

Rehabilitation (VR) services,

the

DARS

Integrated

Employment

Models

There

are

a

variety

of

community

integrated

employment

models

used

in

Virginia

and

across

the

country

such

as:

• Individual

Supported

Employment

is

one

person,

one

job,

with

supports

based

on

the

needs of

the

person

• Entrepreneurship

involves

a

person

starting

a

business

• Business

within

a

business

is

an

employment

model

where

someone

opens

a

complimentary business

within

an

existing

business

(for

example,

a

barista

at

a

local

hotel).

• Group

supported

employment

involves

small

groups

(no

more

than

eight

individuals) working

in

a

community

business

with

ongoing

supports.

The

supports

are

there

to

fully integrate

the

individuals

into

the

work

environment

and

help

them

develop

meaningful relationships

with

their

coworkers

while

supporting

them

with

their

tasks.

1. 5.24 counselor

assigns

him

to

one

of

the

priority

categories.

If

his

priority

category

is

open,

he

will

be

served.

If

it

is

closed,

he

will

be

notified

that

he

is

on

a

waiting

list. DARS decides annually whether to open priority may

be

forwarded

into

the

current

record

or

repeated

on

the

supporting

documentation categories. When a category opens, DARS may serve all clients in that category, or may serve them in the order that they applied for VR. DARS will notify an individual as soon as his category opens and DARS can serve him. After 12 months, if his category remains closed, his counselor will contact him to discuss whether he wishes to stay on the waiting list. DARS will keep his name on the waiting list for as long as he wishes. 125 The goal of each of these employment models and services is to support individuals in integrated work settings, doing meaningful work, for which they are paid at least the minimum or competitive wage and benefits.

Benefits Counseling SCs need not, nor should they, act as benefits advisors to the people they serve. Knowing all the rules governing work and its impact on individual benefits is best left to the experts. Benefits analysis is complicated and work incentives are specific to the type of benefit(s) a person receives. Inaccurate information can lead to an “overpayment” and even a loss of benefits. Income can also have an impact on other federal, state, and local programs including food stamps, Section-8 housing vouchers, etc.

Below is information on experts to whom SCs may refer those they support.

Experts on Benefits and the Services Provided Work incentive planning and assistance (WIPA) projects are funded by the SSA to provide information and benefits planning to enable beneficiaries with disabilities to make informed choices about work. WIPA projects hire and train community work.

Incentives coordinators (CWICs) who work with individuals receiving SSDI and/or SSI to provide in-depth counseling about benefits and the effect of work on those benefits. In Virginia, The vaACCSES - WIPA project provides community work incentives counselors and benefits specialists to provide all SSA disability beneficiaries (including transition-to-work aged youth) with access to benefits planning and assistance services. The ultimate goal of the WIPA project is to assist SSA's beneficiaries with disabilities in meeting their employment goals.

To learn more about the function of these specialists and how to contact them, go to:

• contact the Ticket to Work Help Line at (866) 968-7842 or (866) 833-2967 TTY
• visit Welcome to The Work Site
• visit Ticket to Work
• visit Work Incentives Planning & Assistance (WIPA) Work Incentive Specialist Advocates (WISA) have been certified to provide work incentives counseling services to DARS clients who are receiving SSDI and/or SSI benefits. To learn more about the function of these specialists and how to contact them go to Grants & Special Programs.

Benefits planning service is an individualized analysis and consultation service for recipients of a DD waiver and social security (SSI, SSDI, SSI/SSDI) to understand their personal benefits and explore their options regarding working, how to begin employment, and the impact employment will have on their state and federal benefits.

1. 5.24 126 Integrated Community Involvement True community integration enables people to strive to learn, work, play, and socialize successfully, all while enjoying the benefits of an active, engaged lifestyle. Everyone has a unique potential; a potential to create, grow, learn, and adapt. The community provides opportunities to connect with others and enjoy a multitude of activities and events of many different areas of interest. There is an expectation that people with a DD Waiver have the opportunity to discuss options for integrated community involvement, explore ways to connect with community members, and have the desired supports and services to fully participate in the community in an integrated way. Discussions about integrated community involvement should occur frequently but minimally annually.

Integrated community involvement conversations explore the interests and available options for the individual. Explore their satisfaction or dissatisfaction with current services. Be sure to ask open-ended questions. Exploring barriers is also important and may include identifying and addressing barriers. Ask yourself what related actions will need to be taken to support the individual to enjoy more time in their community? Are there related actions that will be taken?

In the person-centered ISP, the life areas related to community can be defined as follows: For individuals aged 14-17, it is important to explore what they are working on at home and school that will lead to more community participation and inclusion. The discussion for this age group also must include alternative sources for funding, such as parks and recreation, social clubs, and faith-based services. ICI outcomes can fall under most services, not just community engagement. The ratio used to implement the outcome is what matters, not the specific service.

Life area: Integrated Community Involvement Life area: Community Living Use this Life area if there are one or more community involvement outcomes in at least one service at 1:3 or fewer ratio Use this Life area if there are one or more community involvement outcomes at 1:4 or larger ratio

1. 5.24 127 Introduction Adults with DD are increasingly choosing to live in and receive supports in integrated, independent housing settings. These settings have the following characteristics:

• The individual does not reside with a parent, grandparent, or guardian;
• The individual can live in housing types that anyone without a disability lives in, based on income;
• The individual has social, religious, educational, and personal opportunities to fully participate in community life;
• The individual owns or leases the housing unit, or has legal occupancy rights;
• Housing is affordable (the individual pays no more than 30% to 40% of his adjusted gross income);
• Housing is accessible (barrier-free);
• Housing is leased or owned by the person using services; and
• Housing is not contingent upon participation in services, and services are not contingent upon housing.

Support Coordinator’s Role in Integrated, Independent Housing SCs coordinate the person-centered planning team to help individuals with DD obtain and maintain housing, including community housing guides, residential service providers, landlords, and property owners (the Housing Collaboration Map in Appendix 1 illustrates the roles of these team players). This chart outlines the SC’s primary responsibilities and describes these responsibilities in the context of supporting an individual’s integrated, independent housing goals.

Housing

1. 5.24 128 Support Coordinator Primary Responsibilities Support Coordinator’s Housing Responsibilities Offer education and counseling to guide individuals Educate individuals about integrated, independent housing options.

• Review available housing resources.
• Share links to videos and information sessions about housing options.
• Encourage individuals to connect with peers who live in integrated, independent housing.

Explore the person’s vision for housing.

• What does the person’s desired housing arrangement look like?
• Where does the person want to live? With whom?
• What is important to/for the person in housing?

Assess individual needs Assess individual’s preparedness for housing and housing needs

• With whom (if anyone) will the individual live?
• What supports does the individual need to obtain and maintain housing? Who does the person want to provide these supports? Are these supports available?
• Does the person have a realistic budget to obtain and maintain housing? What income and assets does he/she have?
• Does the person have the required documents to obtain housing (e.g., Social Security card, birth certificate, government photo I.D., benefit letters, paystubs, bank statements)?
• What housing features does the person need (e.g., specific location, unit size, accessibility features)?
• What barriers does the person face to obtaining rent assistance and housing (e.g., poor credit, prior evictions or lease violations, criminal history, etc.)?

1. 5.24 129 Develop the individual service plan Based on the assessment above, develop the plan to help the individual transition to and maintain independent housing.

• Identify and get commitments from any roommates and/or live-in aides.
• Outline plans to secure needed supports in housing, including funding sources, providers, and proposed support schedule.
• Determine ways to increase income, reduce expenses and access alternative resources to offset living expenses (e.g., SNAP, fuel assistance, etc.).
• Define financial responsibilities (e.g., who will pay for upfront and ongoing housing expenses and how will payments be made).
• Identify documents needed to apply for housing and who will help secure and complete them.
• Explore properties which may meet the individual’s needs.
• Identify housing assistance programs for which the individual is eligible and would like to apply.
• Investigate approaches to reduce or remove barriers (e.g., reasonable accommodation requests, building or repairing credit, tenant training).

Support Coordinator Primary Responsibilities Support Coordinator’s Housing Responsibilities Link to services and resources Assist individuals with locating or obtaining needed services and resources Coordinate services Based on the plan above, SC activities may include:

• Submitting a DBHDS housing referral package for housing assistance.
• Assisting the individual with completing rent assistance applications and eligibility interviews.
• Supporting the individual at applicant briefings for rent assistance.
• Connecting the person to affordable rental properties that may meet his/her needs and/or accept rent assistance.
• Coordinating resources and services to assist with the housing search, lease review and the move (e.g., family, support services such as Community Housing Guide).
• Helping individuals access funding sources to cover upfront costs to secure housing (e.g., application fees, security and utility deposits, etc.).
• Assisting individuals with requesting reasonable accommodations and modifications in rent assistance programs and rental housing.

1. 5.24 130 Support Coordinator Primary Responsibilities Support Coordinator’s Housing Responsibilities Monitor whether services are achieving intended outcomes* If an individual lives in independent housing and receives no Waiver services in the home, the SC should:

• make two in-home visits per year to review whether the housing environment continues to meet the person’s needs.
• complete two telephone contacts per year with the individual to monitor rent and utility payments and satisfaction with the housing arrangement.
• make two collateral contacts per year with the landlord and two contacts with the rent assistance program to support compliance with the lease and the rent assistance program’s participation requirements.

If an individual lives in independent housing and receives Waiver services in the home, the SC should:

• make one or more, in-home visits per year (depending on the individual’s case management status) to review whether the housing environment continues to meet the person’s needs.
• complete two telephone contacts per year with the individual to monitor rent and utility payments, and satisfaction with housing arrangement.
• make two collateral contacts per year with the landlord, and two contacts with the rent assistance program, to support compliance with the lease and rent assistance program participation requirements.
• review quarterly reports from the service providers to determine whether service providers that support the individual in the home report changes in the person’s housing needs, satisfaction with the housing arrangement, rent/utility payment status, or compliance with lease or rent assistance program requirements. *SCs should reference case management and support coordination requirements for frequency of face-to-face contacts and where these contacts must occur.

1. 5.24 131 Support Coordinator Training, Resources and Tools SCs are required to complete the Independent Housing Training for Support Coordinators within the first 30 days of employment. This training consists of three modules and is available on the Commonwealth of Virginia Learning Center (COVLC). After logging into COVLC, type “Housing” in the search bar. Select the Independent Housing Training for support coordinators (not Community Housing Guides).

DBHDS also has a housing webpage with tools and resources SCs can use to support people as they pursue integrated, independent housing: https://www.dbhds.virginia.gov/developmental-services/housing/resources-for-support-coordinators-and- case-managers DBHDS Regional Housing Coordinators Helping someone obtain and maintain housing can be a daunting task. DBHDS has housing coordinators available in each DBHDS region to provide SCs technical assistance throughout this process. Find your regional housing coordinator at https://dbhds.virginia.gov/developmental- services/housing/housing-team Housing coordinators provide information and guidance on:

• Accessing available housing resources;
• Submitting a DBHDS housing assessment and referral;
• Developing a housing action plan and implementing the plan;
• Locating housing and completing rental and rent assistance applications;
• Preparing reasonable accommodation or modification requests;
• Developing strategies to address fair housing and/or tenant-landlord concerns; and
• Securing resources to cover transition expenses such as security deposits, utility connection fees, and basic furniture and household supplies.

DBHDS Housing Resources The DBHDS Office of Community Housing (OCH) coordinates access to the following integrated, independent housing resources for people with DD. Eligible individuals with developmental disabilities must be age 18 or older and either:

• Transitioning from a skilled nursing facility, an intermediate care facility, the state training center, a group home or other congregate setting and meet the level of functioning criteria for a DD Waiver; or
• Currently receiving BI, FIS, or CL Waiver Services; or
• Determined eligible for and currently on the waitlist to receive a BI, FIS, or CL Waiver slot.

Housing Choice Voucher Special Admissions Preference and the State Rental Assistance Programs These two rental assistance resources are for eligible people with DD. Typically, the individual/household receives a voucher or certificate that can be used at any rental property in the community. Both programs have maximum subsidy limits based on household size. The “gross rent” (e.g., rent plus tenant-paid utilities) of the selected unit must meet the program’s requirements for rent

1. 5.24 132 reasonableness and affordability. The unit must also pass a safety inspection. If the unit is approved, the individual or household will pay 30-40 percent of its monthly adjusted income towards rent, minus an allowance the household can use to offset the cost of tenant-paid utilities. The balance of rent (up to the maximum allowable by the program) is paid directly to the landlord by the rental assistance program administrator.

Rental Properties with a Leasing Preference for the Settlement Agreement Population Certain rental properties that receive special financing from the low income housing tax credit (LIHTC) program have a leasing preference for eligible people with DD. The leasing preference gives individuals in the settlement agreement population priority in applying for available units at these rental properties.

Individuals must still qualify for the apartments (e.g., meet income and other tenant selection criteria).

Rental assistance may or may not be available at the property. For information about rental properties with a leasing preference in your region, contact your regional housing coordinator.

DBHDS Flexible Funding The Flexible Funding program helps people with DD in the Settlement Agreement Population afford the costs associated with (1) making the initial transition to their own rental housing or (2) maintaining housing if they are at risk of eviction. Six Community Services Boards administer this program for the DBHDS regions in the Commonwealth. Examples of costs that Flexible Funding may help cover include: Assistance with the Initial Transition to Housing (one-time allotment of up to $5,000 for the initial move only)

• Holding fees;
• Utility deposits and connection fees;
• Security deposits;
• Moving expenses;
• Essential furniture and other household supplies (these items have maximum allowable payment and reimbursement limits);
• Non-reimbursable environmental modifications or assistive technology;
• Temporary rent to allow completion of environmental modifications;
• Direct support with housing location and pre-tenancy activities;
• Temporary support staff to help individuals acclimate to new housing (e.g., orienting individuals to a new apartment and neighborhood, instruction in use of appliances and environmental controls); and
• Shared living provider start-up activities (e.g., identifying roommate preferences, advertising for and interviewing potential roommates, performing background checks, arranging for required trainings, facilitating discussions of support expectations, developing a supports agreement).

Assistance with Maintaining Housing/Eviction Prevention (one-time allotment of up to $5,000 – can be drawn down until allotment is depleted)

• Security deposits and moving expenses for subsequent transitions;
• Emergency rent and associated late fees;
• Last resort utility assistance;

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• Household management activities (specialized cleaning, pest extermination);
• Unit repairs; and
• Temporary relocation.

SCs complete and submit applications for flexible funding on behalf of individuals. CSB/BHA flexible funding program administrators can either reimburse individuals or their families for eligible expenses, purchase items on behalf of individuals, or pay vendors directly. Documentation of expenses is required. Applications and supporting documentation must be submitted by the deadline. Applications must meet program requirements and flexible funding request approval is based on availability of program funding. For more information, contact your regional housing coordinator or visit https://dbhds.virginia.gov/developmental-services/housing/flexible-funding.

DBHDS Housing Referral Package SCs employed by CSB/BHAs and by CSB/BHA-contracted support coordination agencies are the sole referring agents for DBHDS housing resources. CSB/BHAs may utilize Medicaid SPO case management to complete support coordination activities associated with housing for eligible individuals on the waiver waitlist.

SCs must submit a DBHDS Housing Assessment and Referral Form to access DBHDS housing resources for individuals in the target population. The housing assessment and referral is currently available at https://www.dbhds.virginia.gov/developmental-services/housing/resources-for-support-coordinators-and-case-managers.

If the housing assessment and referral reveals the individual (i) could face major barriers to housing, (ii) has not firmed up the household composition, or (iii) does not have a feasible budget or needed supports, the DBHDS OCH will require that the SC submit a housing action plan for review. The housing action plan addresses issues that could negatively impact the individual’s ability to obtain or to maintain housing. The individual, the SC, and the planning team work together to develop and implement the action plan. Once DBHDS OCH determines the person has a viable plan to address these issues, DBHDS OCH will place the referral in the queue to be assigned a rent assistance resource.

1. 5.24 134 Importance of Reviews There are several different types of reviews and audits in the DD service system. Some are intended to ensure that people are being provided with supports that ensure their health and safety, some reviews examine compliance with regulations, some are quality reviews, and some reviews look at documentation for Medicaid billing justification. It is important for SCs to know and understand the different entities that currently review the DD service system.

Internal All DBHDS-licensed providers are responsible for conducting qualitative and quantitative reviews to evaluate clinical and service quality and effectiveness on a systematic and ongoing basis. SC supervisory and internal quality assurance reviews are conducted regularly to ensure the SC is consistently interpreting and applying licensing regulations and Medicaid requirements. Internal reviews allow the SC to learn methods to improve the quality of services they provide and ensure that the supports are in line with agency standards and state regulations.

External Reviews and audits are conducted by several agencies that are not part of the CSB/BHA or SC organization.

External reviews are often conducted by an independent review organization or a state or federal organization. The goals of external reviews are to provide a review free from conflict of interest, establish standard requirements and qualifications, and to provide fair and impartial reviews.

Department of Behavioral Health and Developmental Services (DBHDS) DBHDS provides oversight to a number of different offices or entities that provide regular reviews of the DD service delivery system. Some of those units are employed by DBHDS and others are contracted to provide the reviews. Below is a description of the four review functional areas associated with DBHDS.

Reviews

1. 5.24 135 DBHDS Office of Licensing (OL) DBHDS licenses services that provide treatment, training, support and rehabilitation to people who have mental illness, developmental disabilities or substance use disorders, to people using services under the Medicaid DD Waiver, or to people with brain injuries using services in residential facilities.

Licensing specialists are employed by DBHDS in the Office of Licensing (OL) to license, monitor and provide oversight and technical assistance to licensed public and private providers that deliver services to people with mental illness, developmental disabilities or substance use disorders. They conduct announced or unannounced onsite inspections, inspect buildings and locations, review staff qualifications, review individual plans, and investigate complaints regarding potential violations of licensing regulations.

More information about this office is available on the licensing section of the DBHDS website.

Permanent licensing regulations can be found here: https://law.lis.virginia.gov/admincode/title12/agency35/chapter105/.

Permanent children’s residential facility licensing regulations are here: https://law.lis.virginia.gov/admincode/title12/agency35/chapter46/.

Emergency (temporary) regulations for either licensing chapter would be listed here: http://register.dls.virginia.gov/emergency_regs.shtml.

DBHDS Office of Human Rights (OHR) Human rights advocates are employed by DBHDS in the Office of Human Rights (OHR). They advocate for the rights of people using services in DBHDS-licensed programs and facilities. They monitor provider compliance with the Human Rights Regulations, and provide consultation and education to people with disabilities, their families, and providers about the regulations. OHR manages the DBHDS human rights dispute resolution process by investigating complaints regarding potential violation of the human rights regulations, reviewing provider’s policies to ensure compliance with the human rights regulations, and providing technical assistance to the local human rights committees (LHRCs).

SCs help protect the basic human rights of people with disabilities. They ensure that people are treated with dignity and respect and are free from abuse, neglect, and exploitation. The SC should ensure that the person and the legal guardian (LG) or authorized representative (AR) are involved in all aspects of care including person-centered planning and signed consents for treatment. If a person’s rights are found to have been violated, the SC should ensure the person, the family, and the LG or AR know who to contact if they have a complaint.

More information about OHR is available at the following sites: https://dbhds.virginia.gov/quality-management/human-rights https://law.lis.virginia.gov/admincode/title12/agency35/chapter115/Quality Service Reviews DBHDS contracts with a separate agency, the Health Services Advisory Group (HSAG), to conduct Quality Service Reviews (QSRs) of those with a developmental disability (DD) who use services under the Department of Justice (DOJ) settlement agreement. This includes people using services through the Medicaid Home and Community-Based (HCBS) Services DD Waivers who live the community. The purpose of the QSRs is to evaluate the quality of services and determine if people are achieving outcomes,

1. 5.24 136 particularly in the areas of person-centered planning, integrated settings, and community inclusion. The QSR consists of person-centered reviews and provider quality reviews. The person using services has a voice as part of each process which is measured through interviews with the person, and the LG or AR, as appropriate. During a QSR, the SC can expect to be interviewed by HSAG reviewers. QSRs also include provider and SC record reviews. HSAG recommends that CSB/BHAs:

• Ensure SC understanding of the expectation for documentation of activities and efforts made to address individual risks by providing additional clinically-based training focusing on proper identification and inclusion of all medical needs documented in most recent assessments to all support coordinators.
• Ensure SC understanding of the expectation for completion of the RAT prior to, or in conjunction with, ISP planning.
• Ensure SC understanding of the expectation for documentation of activities and efforts made to address individual risks by providing additional clinical- based training focusing on proper inclusion of all risks in appropriate Part III outcome.
• Ensure SC understanding of the expectation that ISP documentation contains signatures for all licensed providers responsible for implementation, including the individual and the guardian or authorized representative, as applicable.
• Provide additional clinically-based training focusing on: ensuring SC understanding of proper identification and assessment of new or previously unidentified risks; how to properly document changes in status including relevant follow-up; how to identify deficiencies or discrepancies in support plan or its implementation; and best practices for how to address and mitigate risks incorporating individual’s strengths and preferences with support of planning team.

National Core Indicators (NCI) DBHDS contracts with the Partnership for People with Disabilities at VCU to collect national core indicators (NCI). NCI is a voluntary effort by public DD agencies to measure and track their own performance. The core indicators are standard measures used across states to assess the outcomes of services provided to individuals and families. Indicators address key areas of concern including employment, rights, service planning, community inclusion, choice, and health and safety. NCI gathers information through face-to-face interviews about satisfaction with supports and services from the people who use them. The survey instruments are used by a majority of states in the U.S. Information is also gathered from families about satisfaction with supports and services via mail-in surveys. Major activities of NCI include conducting interviews with people who use supports and services across the state and sending mail-in surveys to family members of people who use supports and services. Analyses and reports of findings may be found at Virginia's NCI website and at the National NCI website.

Department of Medical Assistance Services (DMAS) Reviews Quality management reviews (QMRs) are conducted by QMR reviewers employed by DMAS. QMR reviews are intended to help ensure the health, safety, and welfare of individuals receiving home and community-based waiver services. Federal regulations require that DMAS ensure that necessary safeguards have been taken to protect the health and welfare of the recipients of services, ensure that all

1. 5.24 137 providers are in compliance with applicable state and federal standards, and ensure financial accountability for funds. Reviewers complete QSRs of provider documentation and personnel records for compliance with Medicaid policies and regulations, and provide technical assistance related to onsite reviews. They may refer providers to the DMAS program integrity unit when fraud is suspected or retractions in funding are warranted.

A link to the website is provided on this slide. More information about the QMR is available on the LIS website.

Utilization reviews are financial audits conducted by DMAS program integrity staff or its contractor, Myers and Stauffer, LLC. Audits are conducted to: (i) ensure that Medicaid payments are made for covered services that were actually provided and properly billed and documented; (ii) calculate and initiate recovery of overpayment; (iii) educate providers on appropriate billing procedures; (iv) identify potentially fraudulent or abusive billing practices and refer fraudulent and abusive cases to other agencies; and (v) recommend policy changes to prevent waste, fraud, and abuse.

Support Coordination Quality Review (SCQR) The support coordination quality review (SCQR) process was established to assess and improve the quality of support coordination (also referred to as “case management”) services provided by CSB/BHAs to individuals on one of the home- and community-based services waivers (HCBS Waivers). The results of the SCQR are designed to help determine if these services comply with the Department of Justice Settlement Agreement and CMS requirements. The SCQR has been designed as a tool for CSB/BHAs to utilize for internal review of information as they wish as well as targeted monitoring by DBHDS. The Case Management Steering Committee oversees the development and implementation of the SCQR.

Questions were written to assess compliance with the ten settlement agreement case management indicators (see below) as well as other facets of high-quality support coordination. The purpose of the QSR process is to ensure continuous quality improvement in the services provided to individuals with developmental disabilities through the assessment of provider services. As a SC, your records must show that these ten indicators are being addressed.

Indicators

1. The CSB has offered each person the choice of case manager. (III.C.5.c)
2. Individuals have been offered a choice of providers for each service. (III.C.5.c)
3. The ISP includes specific and measurable outcomes, including evidence that employment goals have been discussed and developed, when applicable. (III.C.5.b.i; III.C.7.b)
4. The ISP was developed with professionals and nonprofessionals who provide individualized supports, as well as the individual being served and other persons important to the individual being served. (III.C.5.b.i; III.C.5.b.ii)
5. The CSB has in place and the case manager has utilized where necessary, established strategies for solving conflict or disagreement within the process of developing or revising ISPs, and addressing changes in the individual’s needs, including, but not limited to, reconvening the planning team as necessary to meet the individuals’ needs. (III.C.5.b.iii; V.F.2)
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7. The case manager assists in developing the person’s ISP that addresses all of the individual’s risks, identified needs and preferences. (III.C.5.b.ii; V.F.2)
8. The case manager assesses risk, and risk mediation plans are in place as determined by the ISP team. (III.C.5.b.ii; V.F.2)
9. The ISP includes the necessary services and supports to achieve the outcomes such as medical, social, education, transportation, housing, nutritional, therapeutic, behavioral, psychiatric, nursing, personal care, respite, and other services necessary. (III.C.5.b.i; III.C.5.b.ii; III.C.5.b.iii; V.F.2)
10. The case manager completes face-to-face assessments that the individual’s ISP is being implemented appropriately and remains appropriate to the individual by meeting their health and safety needs and integration preferences. (III.C.5.b.iii; V.F.2) 10. The case manager assesses whether the person’s status or needs for services and supports have changed and the plan has been modified as needed. (III.C.5.b.iii; V.F.2) Department of Justice (DOJ) Settlement Agreement Independent Reviewer As a result of the DOJ settlement agreement, an independent reviewer appointed by the federal court, who is separate from the Commonwealth of Virginia, conducts reviews and submits reports every six months on their findings. These reviews can include document reviews and discussions with SCs, providers, DBHDS staff, and others in Virginia’s DD system of supports and services. To learn more about the settlement agreement and read past reports, visit: https://dbhds.virginia.gov/doj-settlement-agreement.
11. 5.24 139 Forms that may assist you in supporting individuals with disabilities are available by clicking on the name of each document.

DBHDS Acronyms CRC Contacts by Capacity Area Post Move Monitoring Report REACH Office of Human Rights map DMAS Medicaid or FAMIS appeal request form Service Authorization Board Assignments at DBHDS Sample Right to Appeal letter at-a-glance Service Authorization Guidance at-a-glance When to Submit What at-a-glance Enhanced Case Management Enhanced Case Management Worksheet Enhanced Case Management Q&A Housing Community Housing Guide Collaboration map Regional Housing Specialists list Individual and Family Support A Guide for Developing Preliminary Essential Lifestyle Plan Conversations for Families A Guide for Developing Preliminary Essential Lifestyle Plan Conversations with the Person with whom you are Planning Conversation Book with Family Support Cover letter Choice Packet Cover letter Second Reminder CHAPTER 15: Forms

1. 5.24 140 Person Centered Individualized Service Plan and PCR Checklist for ISP Plan Development Person Centered Review (Quarterly) 2021 Person Centered ISP Guidance Life Areas Cheat Sheet Integrated Community Involvement Fact Sheet Medical A Brief Overview of Psychotropic Medication Use Neurodevelopmental Disorders Office of Integrated Health Person Centered Myths and Misconceptions PCP Manual Resources Social Security Benefits Supports Intensity Scale SIS Scheduling Procedures SIS Reassessment Request Form SIS Reassessment Request Instructions SIS Standard Operating Procedures and Review Process Standard Operating Procedures Review Form SIS Virginia Interview Respondent Info SIS & PCP Process in Virginia (SIS-A & SIS-C) SIS PCP Process in Virginia (SIS-A) Supported Decision-Making SDM Training and Resources at DBHDS SDMA Frequently Asked Questions SDMA Frequently Asked Questions – Plain Language Supported Decision-Making (VITC) CSB Staff Account Registration Guide DSP Orientation Manual Therapeutic Consultation Training for SCs Training
2. 5.24 141 Transition IDEA Part C to Part B technical assistance guide Transitional Funding Transitional Funding Application Transitional Funding Guidelines Virginia Informed Choice VIC Form Waivers At-a-glance Diagnostic Eligibility Review BI Waiver at-a-glance Case management and waitlist eligibility flowchart CL Waiver at-a-glance Compatible-Incompatible Services Grid Navigating the DD Waivers Navigating the DD Waivers (Spanish) Needed services for people on the Waiver waitlist Reserve slot request form Resources for those on the waitlist IFSP First Steps Slot Assignment Review form Waiver Services at-a-glance WaMS WaMS CSB User Guide Waiver Slot Assignment Committee (WSAC) WSAC Application WSAC Introduction Letter WSAC Membership Parameters WSAC Session Operations WSAC Name-ID Key WSAC Review Schedule Signs of Abuse & Neglect Cultural Competency and Self-Assessment Checklist DARS DBHDS Memorandum of Understanding Discharge Protocols Others
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