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  • Suggested Comments for DBHDS Waivers (April 2019)

    Posted on March 31, 2019 by in Policy, State Resources

    Until April 4, 2019, DBHDS is taking comments on the waivers. Providers who treat using therapeutic consultation should take special notice. Here is the suggested comment from VABA. Feel free to copy and paste, or comment on your own.

    Here is the link to make comments.

    Summary of the comments made:

    Summary of Comments:


    The Virginia Association for Behavior Analysis submits the following comments regarding the Three Waivers (ID, DD, DS) Redesign, specifically Therapeutic consultation service:

    • In general, and throughout, when behavior precedes analysis, it should be “behavior” rather than “behavioral”
    • We support the adding of telephone consultation to allowable activities and suggest that HIPAA-compliant video consultation be added as well.  However, later in the service limits, telephone consultation should be removed from the list of in-kind services.
    • For therapeutic consultation, the unit of service should be 15 minutes rather than one hour.  This would invite less confusion on what to do if the service was provided for less or more than one hour.  If service unit remains one hour, it is paramount that the rounding rules are specifically spelled out for providers.
    • Behavior analysts are listed incorrectly in the description of who should provide behavior consultation.  In Virginia, BCBAs and BCaBAs are licensed and the regulations should reflect that.  Board Certified Behavior Analyst ® and Board Certified Assistant Behavior Analyst ® are copyrighted terms and must be listed correctly and with the registration mark if used. 
    • The SIS should not be included in the documentation necessary for the individual’s record.  The SIS assessment does not tend to inform the treatment plan and would be accessible through the case manager.  In addition, therapeutic consultation providers may not be invited to the SIS or may not treat the client at the time when the SIS is being administered as it is only administered tri-annually.
    • There should be more guidelines for the support plan to set standards and protect the waiver recipient.  Each profession should have different guidelines for the plan.  Behavior Consultation Plans should include the following at a minimum:
    • Target behaviors and definitions; includes both behaviors targeted for reduction and replacement behaviors
    • Results of functional assessment, including function, type of assessment, dates, location, who participated, etc.
    • Behavioral objectives
    • Baseline data (could be from assessment)
    • Data collection methods
    • Clear description of treatment methods for behavior reduction and skill acquisition including antecedent and consequence procedures/protocols for each target behavior
    • Functional reinforcer is identified for each behavior targeted for reduction
    • Possible reinforcers (results from preference assessment) and schedule of reinforcement for replacement behaviors
    • Generalization and maintenance strategies
    • Medical contraindication
    • Crisis management (what to do when individual is not responding to the behavior plan and is a danger to self and/or others)
    • Criteria for discharge
    • Benefits and risks associated with treatment and for not receiving treatment
    • Signatures indicating consent from team members and from individual/legal guardian
    • The quarterly reports are actually due three months after the person-centered planning meeting, regardless of when consultation service began.  The portion on the writing of the quarterly report should be written more clearly to let providers know that they need to follow the same schedule.  In addition, all quarterly reports must include data in the form of charts, graphs, or other measures that show that the plan is effective, or if ineffective, how the provider plans to change the service to make it effective.
    • Finally, Therapeutic Consultation, especially behavioral therapeutic consultation, should be an available service for the Building Independence waiver as well.

    Full version of suggested comments included under the regulation to which they apply:

    “Therapeutic consultation” means professional consultation provided by members of psychology, social work, rehabilitation engineering, behavioral analysis, speech therapy, occupational therapy, psychiatry, psychiatric clinical nursing, therapeutic recreation, physical therapy, or behavior consultation disciplines that are designed to assist individuals, parents, family members, and any other providers of support services with implementing the individual support plan.

    Comment:  When behavior precedes analysis, it should be “behavior” rather than “behavioral”

    12VAC30-122-550

    12VAC30-122-550. Therapeutic consultation service.

    A. Service description. Therapeutic consultation service means professional consultation provided by members of psychology, social work, rehabilitation engineering, behavioral analysis/consultation, speech-language pathology therapy, occupational therapy, psychiatry, psychiatric clinical nursing, therapeutic recreation, or physical therapy disciplines that are designed to assist individuals, parents, guardians, family members, and any other providers of support services with implementing the individual support plan. This service shall provide assessments, development of a therapeutic consultation support plan, and teaching in any of these designated specialty areas to assist family members, caregivers, and other providers in supporting the individual enrolled in the waiver. The individual’s therapeutic consultation service support plan shall clearly reflect the individual’s needs, as documented in the assessment information, for specialized consultation provided to family/caregivers and providers. Therapeutic consultation service shall be covered in the FIS and CL waivers.

    Comment:  When behavior precedes analysis, it should be “behavior” rather than “behavioral”

    A therapeutic consultation service support plan is the report of recommendations resulting from a therapeutic consultation that is developed by the professional consultant after he spends time with the individual to determine the individual’s needs in his area of expertise.

    B. Criteria and allowable activities.

    1. To qualify for therapeutic consultation service, the individual shall have a documented need for consultation. Documented need shall indicate that the ISP cannot be implemented effectively and efficiently without such consultation as provided by this covered service and approved through service authorization. The need for this service shall be based on the individual’s ISP and shall be provided to an individual for whom specialized consultation is clinically necessary. Therapeutic consultation service 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 facilitate implementation of individuals’ desired outcomes as identified in their ISP.

    2. Allowable activities for this service shall include:

    a. Interviewing the individual, family members, caregivers, and relevant others to identify issues to be addressed and desired outcomes of consultation;

    b. Observing the individual in daily activities and natural environments and observing and assessing the current interventions, support strategies, or assistive devices being used with the individual;

    c. Assessing the individual’s need for an assistive device for a modification or adjustment of an assistive device, or both, in the environment or service, including reviewing documentation and evaluating the efficacy of assistive devices and interventions identified in the therapeutic consultation plan;

    d. Developing data collection mechanisms and collecting baseline data as appropriate for the type of consultation service provided;

    e. Designing a written therapeutic consultation plan detailing the interventions, environmental adaptations, and support strategies to address the identified issues and desired outcomes, including recommendations related to specific devices, technology, or adaptation of other training programs or activities. The plan may recommend training relevant persons to better support the individual simply by observing the individual’s environment, daily routines, and personal interactions;

    f. Demonstrating (i) specialized, therapeutic interventions; (ii) individualized supports; or (iii) assistive devices;

    g. Training family/caregivers and other relevant persons to assist the individual in using an assistive device; to implement specialized, therapeutic interventions; or to adjust currently utilized support techniques;

    h. Intervening directly, by behavioral consultants, with the individual and demonstrating to family/caregivers or staff such interventions. Such intervention modalities shall relate to the individual’s identified behavioral needs as detailed in established specific goals and procedures set out in the ISP; and

    i. Consulting related to person centered therapeutic outcomes, in person or over the phone.

    Comment: Suggest adding “by HIPAA compliant video consultation”

    C. Service units and limits.

    1. The unit of service shall be one hour.

    Comment:  The unit of service should be 15 minutes rather than one hour.  This would invite less confusion on what to do if the service was provided for less or more than one hour.  If service unit remains one hour, it is paramount that the rounding rules are specifically spelled out for providers.

    2. The servics shall be explicitly detailed in the plan for supports.

    Comment:  services is spelled incorrectly

    3. Travel time, written preparation, and telephone communication shall be considered as in-kind expenses within therapeutic consultation service and shall not be reimbursed as separate items.

    Comment:  This statement contradicts B2i above.  Suggest removing “telephone communication”

    4. Therapeutic consultation shall not be billed solely for purposes of monitoring the individual.

    5. Only behavioral consultation in the therapeutic consultation service may be offered in the absence of any other waiver service.

    6. Other than behavioral consultation, therapeutic consultation service shall not include direct therapy provided to individuals enrolled in the waiver and shall not duplicate the activities of other services that are available to the individual through the State Plan for Medical Assistance. Behavior consultation may include direct behavioral interventions and demonstration of such interventions to family members or staff.

    D. Provider requirements. Professionals rendering therapeutic consultation service, including behavior consultation, shall meet all applicable state licensure or certification requirements.

    1. Behavior consultation shall only be provided by (i) a board-certified behavioral analyst or a board-certified associate behavior analyst or (ii) a positive behavioral supports facilitator endorsed by a recognized positive behavioral supports organization or who meets the criteria for psychology consultation.

    Comment:  In Virginia, BCBAs and BCaBAs are licensed and the regulations should reflect that.  Suggest: “Behavior consultation shall only be provided by (i) a licensed behavior analyst or licensed assistant behavior analyst . . .”  Board Certified Behavior Analyst ® and Board Certified Assistant Behavior Analyst ® are copyrighted terms and must be listed correctly and with the registration mark if used.  (see www.bacb.com for information). 

    2. Psychology consultation shall only be provided by the following individuals licensed in the Commonwealth of Virginia: (i) a psychologist, (ii) a licensed professional counselor, (iii) a licensed clinical social worker, (iv) a psychiatric clinical nurse specialist, or (v) a psychiatrist.

    3. Speech consultation shall only be provided by a speech-language pathologist who is licensed by the Commonwealth of Virginia.

    4. Occupational therapy consultation shall only be provided by an occupational therapist who is licensed by the Commonwealth of Virginia.

    5. Physical therapy consultation shall only be provided by a physical therapist who is licensed by the Commonwealth of Virginia.

    6. Therapeutic recreation consultation shall only be provided by a therapeutic recreation specialist who is certified by the National Council for Therapeutic Recreation Certification.

    7. Rehabilitation consultation shall only be provided by a rehabilitation engineer or certified rehabilitation specialist.

    E. Service documentation and requirements.

    1. Providers shall include signed and dated documentation of the following in each individual’s record:

    a. A copy of the completed age-appropriate assessment as detailed in 12VAC30-122-200.

    Comment:  The SIS assessment is not unique to this service and it is redundant to include it in the individual’s therapeutic consultation record.  It also does not tend to inform the treatment plan.  It would be accessible through the case manager.  In addition, therapeutic consultation providers may not be invited to the SIS or may not treat the client at the time when the SIS is being administered as it is only administered tri-annually.

    b. A plan for support, that contains at a minimum the following elements:

    (1) Identifying information;

    (2) Desired outcomes, support activities, and timeframes; and

    (3) Specific consultation activities.

    c. A written therapeutic consultation support plan detailing the recommended interventions or support strategies for providers and family/caregivers to better support the individual enrolled in the waiver in the service.

    Comment:  Suggest adding more guidelines for the support plan to set standards and protect the waiver recipient.  Each profession should have different guidelines for the plan.  Behavior Consultation Plans should include the following at a minimum:

    • Target behaviors and definitions; includes both behaviors targeted for reduction and replacement behaviors
    • Results of functional assessment, including function, type of assessment, dates, location, who participated, etc.
    • Behavioral objectives
    • Baseline data (could be from assessment)
    • Data collection methods
    • Clear description of treatment methods for behavior reduction and skill acquisition including antecedent and consequence procedures/protocols for each target behavior
    • Functional reinforcer is identified for each behavior targeted for reduction
    • Possible reinforcers (results from preference assessment) and schedule of reinforcement for replacement behaviors
    • Generalization and maintenance strategies
    • Medical contraindication
    • Crisis management (what to do when individual is not responding to the behavior plan and is a danger to self and/or others)
    • Criteria for discharge
    • Benefits and risks associated with treatment and for not receiving treatment
    • Signatures indicating consent from team members and from individual/legal guardian

    d. Ongoing progress note documentation of rendered consultative service that may be in the form of contact-by-contact or monthly notes that must be contemporaneously signed and dated, that identify each contact, the amount of time spent on the activity, what was accomplished, and the professional who made the contact and rendered the service.

    e. If the consultation service extends three months or longer, written quarterly reviews that are completed by the provider and forwarded to the support coordinator. If the consultation service extends beyond one year or when there are changes to the plan for supports, the plan for supports shall be reviewed by the provider with the individual, individual’s family/caregiver, as appropriate, and the support coordinator and shall be submitted to the support coordinator for service authorization, as appropriate.

    Comment:  The quarterly reports are actually due three months after the person-centered planning meeting, regardless of when consultation service began.  Suggest:  “If the consultation service extends three months or longer, written quarterly reviews that are completed by the provider using the quarterly schedule based on when the person-centered planning meeting is due, and forwarded . . . “ or something that lets providers know that they need to follow the same schedule.

    In addition, all quarterly reports must include data in the form of charts, graphs, or other measures that show that the plan is effective, or if ineffective, how the provider plans to change the service to make it effective.

    f. All correspondence to the individual and the individual’s family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.

    g. Written progress note documentation of contacts made with the individual’s family/caregiver, physicians, providers, and all professionals concerning the individual.

    h. A contemporaneously signed and dated final disposition summary that is forwarded to the support coordinator within 30 days following the end of this service and that includes:

    (1) Strategies utilized;

    (2) Objectives met;

    (3) Unresolved issues; and

    (4) Consultant recommendations.

    2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.

    Final Comment:  Therapeutic Consultation, especially behavioral therapeutic consultation, should be an available service for the Building Independence waiver as well.

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