FY2024-2025 Performance Contract Exhibit J: Certified Preadmission Screening Clinicians Requirements

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Background

The Code of Virginia (§37.2-809, §16.1-338-340.1, §19.2-169.6) requires any person who conducts preadmission screening evaluations, for the purposes of temporary detention, to complete a certification program approved by the Virginia Department of Behavioral Health and Developmental Services (the “DBHDS”). 

The certification is valid throughout the Commonwealth.  DBHDS regulates the certification, and recertification, of Certified Preadmission Screening Clinicians (CPSC), through regular compliance inspections, and according to the requirements outlined in this Agreement. DBHDS provides the certification based on the attestation of the individual’s supervisor and executive director that the individual meets the certification requirements and has completed the orientation requirements.

DBHDS is amending the requirements for who may be certified as a Preadmission Screening Clinician.

This change recognizes the wealth of knowledge in our current workforce and the hardships CSBs have faced in recruiting individuals to this role.

1. Requirements for Initial Certification

All CPSC applicants seeking initial certification must meet the educational, professional licensure, orientation and supervision standards outlined herein.

  1. Education and Licensure Requirements
    • CPSC applicants may be a Licensed Mental Health Professional (LMHP),OR 
    • Qualified Mental Health Professional (QMHP) as defined by the Department of Health Professions. 

      CPSCs hired on or before September 30, 2022, and who have fulfilled all requirements, and are an active QMHP or QMHP-T (Qualified Mental Health Professional-Trainee) with the Department of Health Professions, are appropriately certified to provide preadmission screening evaluations throughout the Commonwealth unless there is an interruption in their employment.
    • Applicants may apply that are not currently licensed or certified but hold the appropriate educational attainment and experience while being registered or in supervision with the appropriate professional board to become certified or licensed. 
  2. Orientation Requirements
    All CPSC applicants must successfully complete orientation that meets the following content, observational and experiential requirements:
    • Completion of the requisite online training modules on topics that include legislative and regulatory requirements, disclosure of information, and clinical aspects of risk assessment including the modules on the preadmission screening report and REACH.
    • Completion of an Emergency Services (ES) orientation that meets the content requirements:
      • Orientation to civil commitment process, legal requirements and performance contract related requirements.
      • Orientation to documentation expectations and requirements.
      • Orientation to expectations for use of clinical consultation with peers and supervisors
      • Orientation to local policies and procedures
      • Orientation to role and interface with local law enforcement
      • Orientation to role and interface with magistrates and special justices
      • Orientation to resources for alternatives to hospitalization
      • Orientation to bed registry
      • Orientation to process for securing local private beds
      • Orientation to process for securing state facility beds
      • Orientation to process to access LIPOS or SARPOS funding
      • Orientation to alternatives for special populations [e.g., children, ID/DD or geriatric]Orientation to Federal and State laws about allowed disclosure of information and communication in routine and emergency situations
      • Tour of local facilities (E.g., local hospitals, CSUs, jail, REACH, etc.) as relevant
    • Completion of 40 hours direct observation and direct provision of emergency services, to include conducting preadmission screening evaluations and other forms of crisis services including, but not limited to: knowledge of relevant laws, interviewing skills, mental status exam, substance use assessment, risk assessment, safety planning and accessing community referrals. The 40 hours may be done concurrently.
    • Completion of preadmission screening evaluations under direct observation of an LMHP or LMHP-R (Licensed Mental Health Professional-Resident) CPSC. The number required will be agreed upon by the CSB’s Executive Director and ES Director/Manager.
    • Attestation by a supervisor that the applicant has reached an acceptable level of clinical competence and procedural knowledge to be certified.
    • For a minimum of the first three months of the certification period, newly certified CPSCs are required to consult with a supervisory-level CPSC when the outcome of any preadmission screening evaluation to not recommend hospitalization for an individual under an Emergency Custody Order (ECO).
    • Applicants may begin working independently as a CPSC when an application for certification as well as an attestation of completed orientation and of the ability of the individual to perform the CPSC responsibilities has been submitted to DBHDS at: preadmissionscreening@dbhds.virginia.gov.
    • The documentation associated with orientation and training must be maintained by the primary Community Services Board of employment and be provided to DBHDS for auditing purposes when requested. 

2. Requirements for Maintaining Certification

In addition to the requirements for continuing education, supervision, and quality assurance/review outlined below, all applicants must demonstrate direct involvement in the delivery of emergency services, including the completion of preadmission screening evaluations during the certification period to maintain certification.  

Individuals grandfathered as CPSCs under the July 1, 2016 Certification of Preadmission Screening Clinicians document maintain their grandfathered status under this agreement.

  1. Continuing Education Requirements
    • Applicants for recertification are required to participate in 16 hours of relevant continuing education annually. 
    • The Community Services Board of employment will ensure that the continuing education requirement is met and must be able to provide documentation to DBHDS at any time for auditing purposes. 
    • Individuals who are licensed by the Board of Health Professions may use their required continuing education hours for their license or registration as a qualified mental health professional to achieve this requirement.
    • All applicants are required to complete any new on-line training modules released by DBHDS, within 60 days of release. If a CPSC is out on extended leave, they may prorate these hours accordingly.
  2. Supervision Requirements
    • Applicants for recertification are required to participate in a minimum of 12 hours of individual and/or group supervision, annually.
    • Licensed CPSC supervisors who direct the work of others and provide supervision/consultation to CPSCs conducting preadmission screenings are exempt from this requirement. Supervision may be provided in person, by audio or virtually with two-way audio visual technology. 
    • All staff with a QMHP must meet the required supervisory requirements outlined by the Department of Health Professions.
  3. Quality Assurance/ Quality Improvement Reviews
    • Regardless of the length of the period of certification, and regardless of professional licensure, all applicants are required to participate in quality assurance/quality improvement review activities of at least 5 percent of all preadmission screening evaluations completed, annually. 
    • These reviews must be completed by a supervisor who is a CPSC.
    • Documentation of these reviews and actions taken to improve the documentation and provision of crisis response services including safety planning, using a “least restrictive” mindset for all evaluations, assessing capacity, use of community resources and must be available upon DBHDS request.

3. Requirements for CPSC Supervisors

For the purposes of this document, “supervisor” is defined as a: supervisory level, licensed CPSC, with a minimum of two years’ experience working in crisis services.  Supervisors have the authority to direct the decision making of clinician-level CPSCs and are directly responsible for the oversight of the delivery of emergency/crisis intervention services, to include quality assurance/review activities. 

CPSC supervisors who do not hold a professional license from the Board of Health Professions, but are registered for supervision and meet the minimum of two years’ experience working in crisis services may be utilized with a variance granted by DBHDS. Each variance must outline a timeline and path to bring the individual up to meeting the standard for CPSC Supervisors.

  1. CPSC Supervisors must meet the following:
    • Completion of the Initial Certification process.
    • Continuing Education requirements described under Requirements for Maintaining Certification, Subsection A.
    • Licensed CPSC supervisors who direct the work of others and provide supervision/consultation to CPSCs conducting preadmission screenings are exempt from the annual requirement to participate in a minimum of 12 hours of individual and/or group supervision.
    • Licensed CPSC supervisors who conduct quality review and improvement activities of other CPSCs are exempt from the requirement to complete a preadmission screening assessment and report annually.

4. DBHDS notification of change in employment status

The CSB must notify DBHDS, at preadmissionscreening@dbhds.virginia.gov, if a CPSC leaves the CSB’s employment or transfers to another position within the CSB and will no longer be performing the duties of a CPSC. The CPSC’s certification will be considered expired and subject to compliance with section 5 of this Agreement. For CPSCs who remain with the same employer and will continue to work as a CPSC in any capacity, notification to the Department is not needed.

5. Hiring an individual with prior CPSC experience

If an individual seeks a position as a CPSC, DBHDS will confirm the individual’s certification status upon request received at preadmissionscreening@dbhds.virginia.gov.

  1. If the certification is active and valid, the CSB is required to verify that any additional requirements for continued certification and supervision are met.
  2. Licensed CPSCs whose certification has expired less than 24 months, only need to complete the local orientation for recertification.
  3. CPSCs without professional licensure whose certification has expired less than 12 months, only need to complete the local orientation for recertification.
  4. CPSCs without professional licensure whose certification has expired more than 12 months and licensed CPSCs whose certification has expired more than 24 months must complete the process for initial certification.
  5. If the individual has CPSC experience and does not meet with the new requirements for a CPSC, a variance may be sought from DBHDS.
  6. If the certification has not expired, the individual’s hours for supervision and continuing education may be prorated to allow recertification when current certification expires.

6. Variance Requests

A variance request may be made to DBHDS on a case-by-case basis. A variance request is needed if any of the above criteria for initial or recertification of certified prescreeners or supervisors cannot be met. Approved variances expire on June 30th of each year. Variances received after April 1st will expire the following year on June 30th.  The CSB will be responsible for submitting a report to DBHDS on the individual’s initial or recertification progress within 30 days of the variance expiration date.

The variance request must outline the:

  1. Specific educational and experiential background of the applicant.
  2. Reason the variance is being sought.
  3. Specific monitoring activities the CSB will perform with associated timelines to bring the individual into alignment with the required education and licensure requirements as applicable.

7. DBHDS Quality Assurance and Oversight

DBHDS will ensure compliance with these requirements by conducting reviews of samples of certification documentation during critical incident reviews and at other times as determined by DBHDS. Compliance reviews will include:

  1. Review of documentation demonstrating compliance with orientation requirements.
  2. Reviewing a copy of QMHP certification/registration.
  3. Reviewing a copy of License or supervision enrollment from the Department of Health Professions. This includes annual verification of license status.
  4. Reviewing any actions taken by the Department of Health Professions related to performance of any QMHP or LMHP CPSC.
  5. Reviewing documentation demonstrating compliance with continuing education requirements, including completion, within 60 days of any new modules released by DBHDS.
  6. Reviewing documentation demonstrating the provision of individual and/or group supervision hours for all CPSCs.
  7. Review of documentation demonstrating quality assurance/quality improvement reviews and actions of at least 5 percent of all preadmission screening evaluations completed by each CPSC, including review of results and any subsequent quality improvement activities.  Information identifying individual records reviewed must be available to DBHDS upon request.