Harvest Outreach Center Public Comment on Proposed CPST–School Based Regulations

Thank you for the opportunity to share feedback on the draft manual for the new school-based service that will replace Therapeutic Day Treatment (TDT). While we appreciate DMAS’s goal to strengthen quality and accountability, the current manual contains numerous contradictions and impractical expectations that make the model unworkable for school-based mental health programs,particularly for rural providers.

The following overview reflects our agency’s feedback as an active provider of school-based mental health services that has remained committed to supporting students and families while adapting to the many challenges of implementation and sustainability.

1. Supervision and Oversight Requirements

The manual’s definition of supervision fails to recognize the effectiveness and safety of tele-supervision. It excludes live observation opportunities, shared video reviews, and other secure online methods that have been in use successfully for years. “Face-to-face” supervision should include HIPAA-compliant virtual options to ensure equitable access, especially for rural providers who cannot be physically present at all times.

The proposed 1:9 LMHP supervision ratio and requirement for 24/7 on-call availability are unrealistic and damaging to the workforce. This rule means that one Licensed Professional Counselor (LPC) can only supervise nine staff members total,whether they are full-time, part-time, or relief workers. That restriction makes it nearly impossible to employ part-time Behavioral Health Technicians (BHTs) who fill in or help during peak needs, because even a part-time worker still counts toward the total of nine supervisees. It also prevents agencies from having additional staff available to provide backup coverage or support when needed. It is unclear whether this cap applies strictly to the same nine staff members on an ongoing basis, or if supervisors can temporarily adjust supervision assignments when staff are out for vacation, illness, or other absences.

Without clarification, this rule creates confusion and potential compliance risk. For example, if one of the nine supervised staff takes a week of leave, can another employee temporarily provide services under that supervisor, or would that violate the 9-person limit? In real-world practice, agencies frequently need to adjust staffing to ensure continuity of care for clients.

If the rule is interpreted rigidly, it would make it extremely difficult to manage normal staff turnover, coverage, and schedule changes, particularly in smaller or rural programs. DMAS should clarify whether flexibility will be allowed for temporary substitutions and provide guidance on how agencies can remain compliant while still meeting client needs when staff are unavailable.

Oversight of staff caseloads with this model would include supervision tasks, approving a range of 126-180 daily progress notes a week (this is just referencing 1 form) in addition to oversight of all other clinical and enrollment documentation, direct client care, and 24/7 oversight of staff and client support.

One thing that we really appreciate about this service model is its design to have multiple people supporting each client, allowing for a team approach that blends the strengths of different professionals. However, if each staff member is capped at a strict maximum caseload, this team model becomes impossible. Once every staff member reaches their caseload limit, no one else can join a case,even to provide minimal or short-term support.

The 504 monthly billing unit limit already prevents any one person from being overloaded, so these additional caps only restrict flexibility without improving quality. LPC-Residents (LPC-Rs) and Behavioral Health Technicians (BHTs) could meaningfully support more clients by taking smaller roles,yet under the current draft, they cannot participate at all unless they act as the primary Qualified Mental Health Professional (QMHP). This undercuts the team-based structure that CPST is supposed to rely on.

The combination of limited supervision ratios, inflexible caseload caps, and around-the-clock availability requirements will make it virtually impossible for agencies to staff programs adequately.

Currently, one in three Licensed Professional Counselors (LPCs) in Virginia is under the age of 40, and nearly 90% of those under 40 are women. Requiring 24/7 availability places an unmanageable burden on working parents,primarily women,and threatens to drive clinicians out of the workforce altogether.

Community-based and school-based services operate during business hours (7am-8pm time frame) to meet students’ needs in natural environments,schools, homes, and offices. Unlike emergency rooms or crisis response centers, they are not designed to deliver care 24 hours a day. Requiring them to do so would collapse already strained programs.

Oversight requirements are also inconsistent with state licensure boards and national certification standards. Limiting tele-supervision to half of total supervision hours conflicts with guidelines set by the Virginia Board of Counseling and national programs such as the Advanced Clinical Supervisor and Board Certified Telemental Health Provider credentials. Supervisors should have flexibility to meet requirements through individual and group telesupervision, live observation, consultation, and secure video review.

In practice, these new requirements would force LMHPs to approve hundreds of progress notes weekly, oversee documentation, handle insurance appeals, provide clinical care, and maintain constant on-call availability. These overlapping duties are unsustainable and risk major burnout among supervisors.

2. Workforce Shortages and Administrative Burden

The manual overburdens licensed staff by assigning both administrative and clinical oversight responsibilities without providing additional resources. By requiring LMHPs to sign off on all documentation for all clients across the agency, it prevents the effective use of trained QMHPs who are fully capable of reviewing non-clinical paperwork and supporting direct care staff.

Staffing caps (e.g., 504 units per month per staff) and rigid caseload rules make it impossible to maintain a team-based model of care. These limitations prevent multiple staff members from supporting the same client, even when shared care is clinically necessary. They also restrict part-time and relief staff who play a crucial role in rural and school-based settings.

The combined effect of supervision limits, 24/7 availability, and unit caps leaves agencies in an impossible situation,unable to comply with every rule at once. This will result in fewer available providers and ultimately harm access for children and families.

3. Crisis Coverage and Ethical Conflicts

The manual mandates that crisis support must be available 24 hours per day, 7 days a week, 365 days a year, and that in-person crisis response must be offered. Requiring on-call availability around the clock for non-crisis, school-based programs places agencies in conflict with federal labor laws regarding compensable on-call time and creates conditions that would lead to severe staff burnout.

Additionally, forcing clinicians into constant on-call roles blurs ethical boundaries. It requires counselors to move between therapeutic and evaluative functions without separation, increasing the risk of impairment, ethical violations, and emotional exhaustion. Staff need clear boundaries between their professional and personal lives to preserve their well-being and professional judgment.

Beyond the ethical and legal concerns, there are significant safety implications that the current language does not address. Even law enforcement officers do not enter a potential crisis situation without first assessing risk and determining whether conditions are safe for response. Is the expectation that a mental health provider would respond to a home at midnight or 2 a.m. to intervene with a client who is escalating—possibly to prevent a caregiver from taking the child to the emergency room? Would that provider be expected to call 911 and request law enforcement to accompany them to a private residence? Responding to a crisis in the middle of the night introduces serious safety risks. Family members may be impaired, aggressive, or irrational, and clinicians are not equipped or authorized to manage those situations alone. Where is the line between when a behavioral health provider is expected to respond versus when a situation warrants law enforcement or emergency medical intervention? If the situation is not a significant safety issue, then it is unclear why the situation could not wait until normal working hours when providers can safely and effectively respond. The expectation that school-based mental health providers deliver 24/7, in-person crisis support is not only impractical—it is dangerous. DMAS must clarify realistic crisis protocols that distinguish between clinical support and emergency response, and ensure the safety of both clients and staff.

4. Assessments, Documentation, and Service Definitions

The manual’s assessment requirements are overly complex and duplicative. It is unclear whether the CANS Lifetime replaces or supplements the Comprehensive Needs Assessment (CNA), and whether the two must be completed separately. Clarification is also needed on who can participate in assessments,particularly for young children who cannot complete the CANS independently.

The manual’s definition of progress and engagement is also vague. Terms like “no progress” and “lack of caregiver engagement” are undefined, leaving too much room for interpretation by Managed Care Organizations (MCOs). This could lead to inappropriate service terminations or denials of care. Barriers such as transportation, work schedules, or rural isolation often prevent families from attending frequent in-person meetings. These systemic realities must be recognized to prevent penalizing families for factors beyond their control.

5. Service Model Conflicts

There are several contradictions within the manual itself. For example, “crisis avoidance” language assumes clients can avoid triggers, even when the trigger is a family member or unavoidable environment. Similarly, requiring both “on-site” skill-building and allowing telehealth sessions creates confusion about when and how telehealth may be used.

The restorative skill-building and restorative life skills sections appear nearly identical, using different terms for the same type of intervention. The psychotherapy requirement creates further overlap and may lead to billing denials, particularly when clients already receive outpatient therapy from the same provider. Many students referred for school-based services are not appropriate for outpatient therapy due to the intensity of their needs. Requiring outpatient psychotherapy as a prerequisite wastes time and delays effective intervention.

6. Service Eligibility and Functional Criteria

The level-of-need criteria in the manual are unclear and inconsistent. Some sections require two lifetime domains at level three or higher, while others reference a level four threshold. These inconsistencies make it difficult to determine who qualifies for services and invite arbitrary interpretation by MCOs.

7. Summer Programming and Service Authorization

The new manual eliminates the ability to provide summer programming under CPST–School Based services. Under the current model, summer programming allows continued support through structured therapeutic groups, summer school sessions, and community-based interventions. Without this, students must be discharged at the end of the school year and then reapply for services in the fall,an interruption that insurers may use to deny care.

Summer programming plays a critical role in assessing functioning outside of school, building peer relationships, and maintaining clinical stability. Removing this option will disrupt continuity of care and increase regression among high-need students.  In addition, the absence of ongoing summer services will likely place added strain on other community systems—such as crisis response, juvenile justice, and hospital emergency services—as youth lose access to the preventive supports that help keep them stable and connected.

8. Exclusions and Contradictions

Sections C and D of the “Exclusions and Service Limitations” are written in conflict with each other and need clarification. Section G lacks guidance on what services may be offered during summer months when students are not in school. Section I contradicts itself by defining Tiered services as requiring 24/7 availability while simultaneously excluding crisis care from coverage.

9. Accreditation, Implementation, and Feasibility

Providers need realistic timelines to plan training, staffing, and compliance. The manual’s expectations for supervision hours (4–6 per month), documentation, and 24/7 crisis readiness far exceed available resources. Providers will not be able to maintain compliance without additional funding or flexibility.

Phần kết luận

In its current form, the proposed CPST–School Based service model is not operationally or financially sustainable. It introduces overlapping rules that conflict with one another, overextends clinical staff, and fails to consider the realities of school-based work.

If implemented as written, these regulations will cause severe workforce shortages, service interruptions, and barriers to access,especially for children in rural and underserved areas.

Harvest Outreach Center and other community-based partners stand ready to collaborate with DMAS to develop a framework that strengthens oversight without dismantling the workforce or reducing access to care.

Thank you for taking the time to consider this feedback. We share the same goal: ensuring Virginia’s children and families receive consistent, compassionate, and effective mental health support. We want to be part of the solution,please work with us to make this model both ethical and sustainable.