While Virginia is focused on transitioning people with disabilities from institutions to home- and community-based settings, the Commonwealth should also focus on ensuring the well-being of those who remain in institutions. Virginia has closed four of five intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs) that are operated by the Commonwealth, known as Training Centers, but the vast majority of ICF/IIDs are not operated by Virginia and will remain open. The utilization and cost of these other ICF/IIDs have increased in recent years, and there have been minimal consequences to providing substandard care (see Table 1 on page ii of the report).

Virginia has improved its oversight of ICF/IIDs in recent years, but more work remains. The Virginia Department of Behavioral Health and Developmental Services (DBHDS) has reduced inappropriate admissions, increased opportunities to discharge children, and improved enforcement of state licensing laws. These efforts are commendable. However, the Commonwealth continues to rely too heavily on ICF/IIDs to regulate themselves, which poses a conflict of interest that jeopardizes the well-being of the people who live there.

Virginia has no restrictions on the development of smaller ICF/IIDs, despite its focus on transitioning people from institutions to less integrated settings. In recent years, Virginia actively solicited new ICF/IIDs in order to quickly accommodate people leaving Training Centers. This need should lessen in the coming years, however, now that the closure of Training Centers is complete and home- and community-based alternatives continue to be expanded. The Commonwealth should reevaluate its approach to regulating ICF/IID development accordingly.

Virginia has not adequately ensured that adults who remain in ICF/IIDs continue to need and want ICF/IID services. DBHDS recently improved its discharge processes for the two non-state-operated ICF/IIDs that serve children. However, the vast majority of Virginia’s ICF/IIDs serve adults. These facilities, in most cases, appear to be solely responsible for ensuring that their adult residents still need and want ICF/IID services. This approach poses a conflict of interest that could jeopardize people’s right to make an informed choice. Consequently, there may be people remaining in institutions who want to be served in the community.

Virginia has focused on avoiding institutional costs by transitioning people to home- and community-based settings, but has overlooked the cost of caring for people who remain in ICF/IIDs. Medicaid reimbursement rates have varied widely across ICF/IIDs and have increased over time. Reimbursement rates for non-state-operated ICF/IIDs are subject to a ceiling, but the ceiling may be artificially high. Unlike most other states, Virginia’s reimbursement methodology appears to lack incentives for providers to be cost efficient. Each dollar that supports inefficient ICF/IID operations could be redirected to home- and community-based services.

Virginia has not adequately enforced laws that govern ICF/IID quality of care. The Virginia Department of Health (VDH) is responsible for annually certifying that the facilities meet federal conditions for Medicaid participation. However, VDH has not completed these certifications on time, has identified violations at a much lower rate than other states, has not adequately verified that corrective actions were implemented, and has not used additional enforcement tools that are available beyond Plans of Correction. DBHDS is responsible for ensuring that facilities comply with state licensing and human rights laws. Nevertheless, DBHDS has not assessed the adequacy of services and supports, has relied heavily on providers to investigate critical incidents and has been reluctant to use enforcement tools beyond Corrective Action Plans.

Overall, the Commonwealth’s oversight of ICF/IIDs is fragmented across three state agencies. Both VDH and DBHDS oversee ICF/IID utilization, via a Certificate of Public Need process and limits on facility size, but their regulations do not align. Both VDH and DBHDS oversee the quality of care, via certification and licensure processes that operate independently of each other. The Department of Medical Assistance Services (DMAS) issues Medicaid payments to ICF/IIDs, which are supposed to be contingent on the provision of active treatment to eligible individuals, but it is not clear whether DMAS has taken action accordingly. This fragmentation likely limits Virginia’s ability to effectively oversee ICF/IIDs.

The Virginia Board for People with Disabilities offers 26 recommendations to improve the well-being of Virginians with disabilities who live in ICF/IIDs. The Board’s recommendations are listed below, grouped into four main goals.