Agencies | Governor
Virginia Regulatory Town Hall

Proposed Text

Action:
Children's Mental Health Waiver Program
Stage: Fast-Track

Part II

Children''s Mental Health Waiver

12VAC30-135-100. Definitions.

The following words and terms when used in this regulation shall have the following meanings unless the context clearly indicates otherwise:

"Activities of daily living" or "ADLs" means personal care tasks, e.g., bathing, dressing, toileting, transferring, and eating/feeding. A client’s degree of independence in performing these activities is a part of determining appropriate level-of-care and services.

"Agency-directed model" means services provided by a participating provider and where the provider is responsible for hiring, training, supervising, and firing of the staff.

"Appeal" means the process used to challenge adverse actions regarding services, benefits and reimbursement provided by Medicaid pursuant to 12VAC30-110 and 12VAC30-20-500 through 12VAC30-20-560.

"Approve" means the Department of Medical Assistance Services (DMAS) or a DMAS-contracted entity authorizes a participating provider’s request for services, on behalf of a client, as medically necessary and meeting DMAS criteria for reimbursement.

"Assessment" means a face-to-face meeting conducted to identify a client’s physical, emotional, behavioral, and social strengths, preferences, and needs. Assessments are performed by a DMAS-authorized provider prior to the development of the individualized service plan (ISP) and comprehensive service plan (CSP).

"Barrier crime" means those crimes as defined at §32.1-162.9:1 or 37.2-416 of the Code of Virginia.

"Behavioral health authority" or "BHA" means the local agency, established by a city or county or combination of counties or cities or cities and counties under Chapter 1 (§37.2-100 et seq.) of Title 37.2 of the Code of Virginia, that plans, provides, and evaluates mental health, mental retardation, and substance abuse services in the locality or localities that it serves.

"Case management" means the assessing and planning of services; linking the client to services and supports identified in the comprehensive service plan (CSP); assisting the client directly for the purpose of locating, developing or obtaining needed services and resources; coordinating services and service planning with other agencies and providers involved with the client; enhancing community integration; making collateral contacts to promote the implementation of the CSP and community integration; monitoring to assess ongoing progress and ensuring services are delivered; and education and counseling that guides the client and develops a supportive relationship that promotes the CSP.

"Case manager" means the individual on behalf of a DMAS participating provider possessing a combination of work experience and relevant education that indicates that the individual possesses the knowledge, skills and abilities, at the entry level to provide the services described, at 12VAC30-50-420 through 12VAC30-50-430 or 12VAC30-50-480 or 12VAC30-50-130 B 5 a for case management services. The case manager may be the provider of Intensive In-Home Services or the Treatment Foster Care Case Manager or other provider as designated by DMAS.

"Centers for Medicare and Medicaid Services" or "CMS" means the unit of the federal Department of Health and Human Services that administers the Medicare and Medicaid programs.

"Child" means, for the purpose of this regulation, an individual under the age of 21 years.

"Client" means the person receiving the services.

"CMH waiver" means the Children’s Mental Health §1915(c) home and community-based services demonstration waiver.

"Community services board" or "CSB" means the local agency established by a city or county or combination of cities and/or counties under Chapter 5 (§37.2-500 et seq.) of Title 37.2 of the Code of Virginia, that plans, provides, and evaluates mental health, mental retardation, and substance abuse services in the jurisdiction or jurisdictions it serves.

"Community transition services" means services that are provided to individuals who are leaving the PRTF and have chosen to receive services in the community. Community transition services include assessment of the child and family; assistance with meeting the requirements of waiver enrollment; referral for Medicaid eligibility; developing a community plan of care in coordination with the family, CSA (if involved), and other involved parties; identifying community service providers; and monitoring the initial transition to the community.

"Companion" means, for the purpose of these regulations, an individual who provides companion services.

"Companion services" means assistance with skill development and with understanding family interaction, behavioral interventions for support and safety, nonmedical care, nonmedical transportation, community integration, and rewarding appropriate behaviors. This service is available through both a consumer-directed (CD) and agency-directed delivery approach and shall not exceed eight hours in one day.

"Comprehensive Services Act" or "CSA" means a collaborative system of services and funding that is child-centered, family-focused, and community-based when addressing the strengths and needs of troubled and at-risk youth and their families.

"Comprehensive service plan" or "CSP" means the overall service plan that addresses the total needs of the client in all life areas. The CSP incorporates the ISPs developed for each individual service. The CSP defines and describes the goals, objectives and expected outcomes of service(s). The client or family/caregiver, as appropriate, will be involved to the maximum extent possible in the development and revision of the CSP. The CSP includes, at a minimum: (i) a summary or reference to the assessment; (ii) goals and measurable objectives for addressing each identified need; (iii) the services, supports, and frequency of service to accomplish the goals and objectives; (iv) target dates for accomplishment of goals and objectives; (v) estimated duration of service; (vi) the role of other agencies if the plan is a shared responsibility; and (vii) the staff responsible for coordination and integration of services, including the staff of other agencies if the plan is a shared responsibility.

"Consumer-directed model" or "CD" means services for which the client or family/caregiver is responsible for hiring, training, supervising, and firing of the staff.

"Consumer-directed services facilitator" means the DMAS-enrolled provider who is responsible for supporting the client by ensuring the development and monitoring of the CD services individualized service plan (ISP), and completing ongoing review activities as required by DMAS for CD companion services and CD respite services.

"Deny" means DMAS or a DMAS-contracted entity denies a participating provider’s request for services, on behalf of a client, as not medically necessary or not meeting DMAS criteria for reimbursement.

"DMAS" means the Department of Medical Assistance Services or its contractors.

"DMAS staff" means individuals employed by DMAS.

"DMHMRSAS" means the Department of Mental Health, Mental Retardation and Substance Abuse Services.

"DSM-IV" means the Diagnostic and Statistical Manual of Mental Disorders that is the standard classification of mental disorders used by mental health professionals.

"DSM-IV-TR" means the text revision of the DSM-IV, published in July 2000, which corrected errors identified in the DSM-IV and included numerous changes to the classification (i.e., disorders were added, deleted, and reorganized), to the diagnostic criteria sets, and to the descriptive text.

"DSS" means the Department of Social Services.

"Enroll" means that a client has been added to the CMH waiver after it has been determined that the client meets all of the eligibility requirements for the waiver.

"Environmental modifications" means physical adaptations to a client’s home or primary place of residence or primary vehicle, which provide direct medical or remedial benefit to the client. These adaptations are necessary to ensure the health, welfare, and safety of the client, or enable the client to function with greater independence in the home. Without these adaptations, the client would require institutionalization in a psychiatric residential treatment facility (PRTF).

"EPSDT" means the "Early Periodic Screening, Diagnosis and Treatment" program administered by DMAS for children under the age of 21 according to federal guidelines that prescribe specific preventive and treatment services for Medicaid-eligible children as defined in 12VAC30-50-130.

"Family/caregiver" means the family, legal guardian, neighbor, friend, companion or co-worker, or any person who provides uncompensated care, training, guidance, companionship or support to a person served under this waiver.

"Family/caregiver training" means training and counseling services provided to families or caregivers of clients receiving services in the CMH waiver. Training includes instruction about treatment regimens and behavioral plans specified in the ISP, and shall include updates as necessary to safely maintain the client at home. Counseling may be provided to the family/caregiver to improve and develop the family’s/caregiver’s skills in dealing with life circumstances of parenting a child with special needs and help the client remain at home. All training/counseling will be provided on a face-to-face basis.

"Fiscal management service" or "FMS" means an agency or organization within DMAS or contracted by DMAS to handle employment, payroll, and tax responsibilities on behalf of clients who are receiving CD respite and companion services.

"Health, welfare, and safety standard" means that a client’s right to receive a waiver service is dependent on a finding that the client needs the service, based on appropriate assessment criteria and a written CSP, and that services can be provided safely in the community.

"Home and community-based waiver services" or "waiver services" means a variety of home and community-based services reimbursed by DMAS as authorized pursuant to §1915(c) of the Social Security Act designed to offer clients an alternative to institutionalization. Clients may be pre-authorized to receive one or more of these services either solely or in combination, based on the documented need for the service in order to discharge the client from a PRTF.

"Individualized service plan" or "ISP" means the specific service plan developed by the service provider related solely to the specific tasks required of that service provider. The client will be involved to the maximum extent possible in the development and revision of the ISP. The ISP helps to comprise the overall CSP. The ISP includes, at a minimum: (i) a summary or reference to the assessment; (ii) goals and measurable objectives for addressing each identified need; (iii) the services, supports, and frequency of service to accomplish the goals and objectives; (iv) target dates for accomplishment of goals and objectives; (v) estimated duration of service; (vi) the role of other agencies if the plan is a shared responsibility; and (vii) the staff responsible for coordination and integration of services, including the staff of other agencies if the plan is a shared responsibility.

"In-home residential supports" means agency-directed services that increase or maintain personal self sufficiency, and facilitate the client’s achievement of community inclusion and remaining in the home. The supports may be provided in the client’s residence or in community settings. Community living supports provides assistance to the family in the care of their child, while facilitating the client’s independence and integration into the community. The service also includes communication and relationship-building skills, and participation in leisure and community activities. These supports must be provided directly to, or on behalf of, the client enabling the client to attain or maintain his maximum potential. These supports may serve to reinforce skills or lessons taught in school, therapy, or other settings.

"Instrumental activities of daily living" or "IADLs" means tasks such as meal preparation, shopping, housekeeping, laundry, and money management.

"Legal guardian" means a person who has been legally authorized to take care of and make decisions for the client in order to protect the interests of a minor client or an adult who has been declared by the circuit court to be incapable of administering his own affairs. The powers and duties of the guardian are defined by the court and are limited to matters within the areas where the client has been determined to be incapacitated.

"Level-of-care" means the psychiatric residential treatment facility (PRTF) criteria. Review of a client’s level-of-care requires the case manager to assure that the client continues to meet the PRTF criteria.

"Licensed mental health professional" or "LMHP" means a clinician in the human services field as defined at 12VAC30-50-226.

"Participating provider" means a person, institution, facility, agency, partnership, corporation, or association that meets the standards and requirements set forth by DMAS, and has a current, signed provider participation agreement with DMAS.

"Pend" means delaying the consideration of a provider’s request, on behalf of a client, for services until all required information is received by the preauthorization entity.

"Person-centered planning" means a process, directed by the client or family/caregiver, as appropriate, with assistance as needed from others involved in the care of the child. Person-centered planning shall be intended to identify the strengths, capacities, preferences, needs and desired outcomes of the client.

"Personal care agency" means a participating provider that renders services designed to prevent or reduce institutional care by providing eligible clients with companions and assistants who provide companion or respite services.

"Preauthorization" means the process to approve specific services for a client by a Medicaid-enrolled provider prior to service delivery and reimbursement.

"Preauthorized" means that an individual’s comprehensive service plan has been approved by DMAS or a DMAS-approved entity prior to commencement of the service by the service provider for provision and reimbursement of services.

"Primary caregiver" means the primary person who consistently assumes the role of providing direct care and support of the client to live successfully in the community without compensation for providing such care.

"Psychiatric residential treatment facility" or "PRTF" means a facility that provides 24-hour-per-day specialized, highly organized, intensive, and planned therapeutic interventions to children that are utilized to treat severe mental, emotional, and behavioral disorders.

"Qualified mental health professional" or "QMHP" means a clinician in the human services field as defined at 12VAC30-50-226.

"Respite care agency" means a participating provider that renders services designed to prevent or reduce inappropriate institutional care by providing respite services to eligible clients for their caregivers.

"Respite services" means services provided to clients and their families to offer relief to unpaid caregivers. Respite services will be provided in the client’s home or place of residence, in the community, or a licensed respite facility, such as a group home. This service is available through both a CD and agency-directed delivery approach.

"Screening" means the process to evaluate the medical, emotional, psychiatric, and social needs of clients referred for screening to determine client’s eligibility to be discharged from a PRTF, and to authorize Medicaid-funded community-based care for those clients who meet the CMH waiver eligibility criteria.

"Screener" means the entity or entities identified by DMAS that is responsible for performing screening for the CMH waiver.

"Serious emotional disturbance" or "SED" means a serious mental health problem in children ages birth through 21 that can be diagnosed under the DSM-IV-TR, or exhibited by all of the following: (i) problems in personality development and social functioning that have been exhibited over at least one year’s time; and (ii) problems that are significantly disabling based upon the social functioning of most children that age; and (iii) problems that have become more disabling over time; and (iv) service needs that require significant intervention by more than one agency.

"Service provider" means the entity providing direct services to the client.

"Services facilitator" means the participating provider who is responsible for supporting the client by ensuring the development and monitoring of the CD Services ISP, providing employee management training, and completing ongoing review activities as required by DMAS for services with an option of a CD model. These services include companion and respite services.

"State Plan for Medical Assistance" or "the Plan" means the Commonwealth’s legal document approved by CMS identifying the covered groups, covered services and their limitations, and provider reimbursement methodologies as provided for under Title XIX of the Social Security Act.

"Therapeutic consultation" means services that provide expertise, training, and technical assistance by licensed professionals to assist family members, caregivers, and other service providers in supporting the client. This service includes the assessment of the client and family strengths, observation, and developing, with the family, a culturally sensitive ISP.

"Uniform Assessment Instrument" means the uniform assessment instrument, as designated by DMAS, used to measure functional outcomes for children. This tool is used by the screener as one component of its assessment and is used to inform but not dictate a level-of-care. The completion of this tool is required for children who participate in the CMH waiver. This tool is separate from the UAI used for long-term care services in other home and community-based services waivers.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. December 1, 2007.

12VAC30-135-110. (Reserved.)

12VAC30-135-120. General coverage and requirements for Children’s Mental Health Waiver services.

A. Waiver service populations. Home and community-based waiver services shall be available through a §1915(c) of the Social Security Act waiver for clients under the age of 21 who have resided in a PRTF for at least 90 days and have been determined to continue to meet PRTF level-of-care, but with additional supports could reside in the community.

B. Required documentation, as identified by DMAS, for admission to the CMH waiver must be submitted to DMAS in order for the client to be enrolled. Upon determination by DMAS or a DMAS-contracted entity that the client is appropriate for admission to the waiver, the case manager or screener will work with the client family/caregiver, the facility currently housing the client, and client/family/caregiver-selected providers of community-based services to determine an appropriate transfer date.

C. Covered services.

1. Covered services shall include respite services (both CD and agency-directed), in-home residential supports, companion services (both CD and agency-directed), family/caregiver training, environmental modifications, community transition services and therapeutic consultation.

2. These services shall be medically appropriate and necessary to maintain the client in the community. Federal waiver requirements provide that the overall costs of community care shall be no more than the overall costs that would have been incurred at the same level of service in the PRTF.

3. Waiver services shall not be furnished to clients who are inpatients of a hospital, nursing facility, intermediate care facility for persons with mental retardation, inpatient rehabilitation facility, or a PRTF consistent with federal waiver limitations.

4. Under this §1915(c) waiver, DMAS waives §1902(a) (10)(B) of the Social Security Act related to comparability.

D. Requests for services. All requests for waiver services by CMH waiver clients will be reviewed under the health, welfare, and safety standard. This standard assures that a client’s right to receive a waiver service is dependent on a finding that the client needs the service, based on appropriate assessment criteria and a written CSP and that services can safely be provided in the community.  If the determination is made that these services cannot be safely provided to a client, then such clients shall not be approved for this waiver.

E. Medicaid reimbursement is available only for services provided when the client is present and when a qualified provider is providing the services. If the client is absent, such as in a hospitalization, no reimbursement will be provided for these waiver services.

F. Appeals. Individual appeals shall be considered pursuant to 12VAC30-110-10 through 12VAC30-110-380. Provider appeals shall be considered pursuant to 12VAC30-10-1000 and 12VAC30-20-500 through 12VAC30-20-560.

G. Reevaluation of service need and utilization review. Reviews and updates of the CSP and level-of-care must meet the requirements as specified by DMAS. Providers shall meet the documentation requirements as specified by DMAS and DMAS will conduct quality management reviews for services rendered. Services failing to meet DMAS’ quality management standards shall not be reimbursed or shall be subject to payment recoveries.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. December 1, 2007.

12VAC30-135-130. (Reserved.)

12VAC30-135-140. Client eligibility requirements and intake process.

A. Virginia will apply the financial eligibility criteria contained in the State Plan for the categorically needy. Under this waiver, clients must meet the financial and nonfinancial Medicaid eligibility criteria and meet the PRTF institutional level-of-care criteria. DMAS shall be the single state agency authority responsible for the supervision and administration of the CMH waiver.

B. The following three criteria shall apply to all CMH waiver services:

1. Clients qualifying for CMH waiver services must have a demonstrated need for the service resulting in significant functional limitations. The need for the service must arise from the client having a SED and meeting the level-of-care for admission to a PRTF;

2. The services described in the ISP, and services as delivered, must be consistent with the Medicaid definition of each service; and

3. Services must be recommended based on a current assessment using a DMAS-approved assessment instrument and a client’s demonstrated need for each specific service.

C. Assessment, screening, authorization and enrollment in home and community-based care services.

1. To ensure that Virginia’s CMH waiver serves only clients who would otherwise remain in a PRTF, home and community-based care services shall be considered only for clients who have resided in a PRTF for at least 90 days to ensure that the client’s condition has been stabilized. Home and community-based care services shall be the critical service that enables the client to be discharged home rather than remaining in a PRTF. Clients must receive at least one CMH waiver service to remain in the waiver.

2. CMH waiver services must be determined by DMAS or a DMAS-contracted entity to be an appropriate service alternative as defined in these regulations to remaining in a PRTF.

3. The client shall be recommended for CMH waiver services after completion of a comprehensive assessment of the client’s needs and available supports. The completion of an assessment is mandatory before the client can be enrolled in the CMH waiver and Medicaid assumes payment responsibility for the waiver services.

4. The CMH waiver screener shall gather relevant medical, social, and psychological data and identify services to meet the client’s needs in the community.

5. The client or family/caregiver, as appropriate, must be offered the choice of CMH waiver services or to remain in the PRTF. If the client chooses CMH waiver services, the client must also be offered the choice of waiver providers.

6. The screener shall explore alternative settings and services to provide the care needed by the client.

7. Medicaid will not pay for any home and community-based care services delivered prior to the authorization date approved by DMAS or a DMAS-contracted entity. Any CSP for home and community-based care services must be preapproved by DMAS prior to Medicaid reimbursement for waiver services.

D. Screening for the CMH waiver.

1. Clients requesting CMH waiver services will be screened and will receive services on a first-come, first-served basis based on the availability of services in the community to support the client.

2. To be eligible for CMH waiver services, the client must:

a. Have been a resident of a PRTF for at least 90 days prior to applying for the CMH waiver;

b. Continue to meet the PRTF criteria described in 12VAC30-50-130;

c. Have services identified in the community to meet the client’s needs;

d. Have a case manager assigned; and

e. Continue to meet Medicaid eligibility criteria.

E. Waiver approval process: authorizing and accessing services.

1. The screener is the entity responsible for assessing the client to determine if the client meets the criteria for admission to the CMH waiver.

2. If a client is a CSA client, the screener shall be the CSA representative. If the client is not a CSA client, the screener shall be the mental health or treatment foster care case manager.

3. Once the screener has determined that a client meets the eligibility criteria for CMH waiver services and the client or family/caregiver, as appropriate, has chosen this program, the client or family/caregiver will be provided with a list of available service providers. The client or family/caregiver, as appropriate, must be given a choice of providers if there is more than one provider available that can meet the client’s needs. The client or family/caregiver, as appropriate, must also be given a choice of CD or agency-directed respite and companion services, if the client is eligible for these services.

4. When all required information has been submitted to DMAS or its contractor for preauthorization, DMAS or the contractor will have 10 business days to review preauthorization requests. If the request is approved, the client will be sent written notification of enrollment in the CMH waiver and services may begin.

5. Only CMH waiver services authorized on the CSP by the screening entity according to DMAS policies may be reimbursed by DMAS.

6. All CSPs are subject to approval by DMAS.

F. Reevaluation of service need.

1. The comprehensive service plan (CSP).

a. The CSP shall be reviewed at intervals as determined by DMAS with the case manager, client, family/caregiver, service providers, consultants, and others involved in the care of the client based on relevant, current assessment data.

b. The case manager is responsible for continuous monitoring of the appropriateness of the client’s services and revisions to the CSP as indicated by the changing needs of the client. The case manager must review the CSP at least every three months to determine whether service goals and objectives are being met and whether any modifications to the CSP are necessary.

c. Any modification to the amount or type of services in the CSP must be approved by the client or family/caregiver, as appropriate, and be pre-authorized by DMAS.

2. Review of level-of-care.

a. The case manager shall complete a reassessment annually, in coordination with the client, family/caregiver, service providers, consultants, and others involved in the care of the client, to ensure that the client continues to meet the PRTF criteria. The reassessment shall include the completion of the assessment instrument and any other appropriate assessment data. If warranted, the case manager shall coordinate a medical examination and a mental health assessment for the client. The CSP shall be revised as appropriate.

b. A new mental health assessment shall be required whenever the current mental health assessment is no longer reflective of the client’s current condition.

3. The case manager will monitor the service providers’ ISPs to ensure that all providers are working toward the identified goals of the client.

4. Case managers will be required to conduct a minimum of quarterly face-to-face visits for all CMH waiver clients.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. December 1, 2007.

12VAC30-135-150. (Reserved.)

12VAC30-135-160. Participation standards for home and community-based waiver services participating providers.

A. Requests for participation. Requests for participation from providers will be evaluated to determine whether the provider applicant meets the basic requirements for participation.

B. Providers approved for participation shall, at a minimum, perform the following activities:

1. For services that require licensure and/or certification, the provider must meet all licensure and/or certification requirements pursuant to 42 CFR 440.50 and 42 CFR 440.60 and any other applicable state or federal requirements;

2. The ability to document and maintain client case records in accordance with state and federal requirements;

3. Immediately notify DMAS in writing of any change in the information that the provider previously submitted to DMAS;

4. Assure freedom of choice to the client or family/caregiver, as appropriate, in seeking services from any institution, pharmacy, practitioner, or other provider qualified to perform the service or services required and participating in the Medicaid program at the time the service or services are performed;

5. Assure the freedom of the client or family/caregiver, as appropriate, to refuse medical care, treatment and services;

6. Accept referrals for services only when staff is available to initiate services and perform such services on an ongoing basis;

7. Provide services and supplies to clients in full compliance with Title VI of the Civil Rights Act of 1964, as amended (42 USC §2000d et seq.), which prohibits discrimination on the grounds of race, color, or national origin; the Virginians with Disabilities Act (§51.5-1 et seq. of the Code of Virginia); §504 of the Rehabilitation Act of 1973, as amended (29 USC §794), which prohibits discrimination on the basis of a disability; and the Americans with Disabilities Act, as amended (42 USC §12101 et seq.), which provides comprehensive civil rights protections to clients with disabilities in the areas of employment, public accommodations, state and local government services, and telecommunications;

8. Provide services and supplies to clients of the same quality and in the same mode of delivery as are provided to the general public;

9. Submit charges to DMAS for the provision of services and supplies to clients in amounts not to exceed the provider’s usual and customary charges to the general public and accept as payment in full the amount established by DMAS’ payment methodology beginning with the onset of the client’s authorization date for the waiver services;

10. Use program-designated billing forms for submission of charges;

11. Maintain and retain business and professional records sufficient to document fully and accurately the nature, scope, and details of the services provided;

a. In general, such records shall be retained for at least six years from the last date of service or as provided by applicable state or federal laws, whichever period is longer. However, if an audit is initiated within the required retention period, the records shall be retained until the audit is completed and every exception resolved. Records of minors shall be kept for at least six years after such minor has reached the age of 18 years.

b. Policies regarding retention of records shall apply even if the provider discontinues operation. DMAS shall be notified in writing of storage location and procedures for obtaining records for review should the need arise. The location and agent, or trustee shall be within the Commonwealth of Virginia.

c. Documentation must be maintained that indicates the date, type of services rendered, and the number of hours/units provided, including the specific time frames.

12. Agree to furnish information on request and in the form requested by DMAS, the Attorney General of Virginia or his authorized representatives, federal personnel, and the state Medicaid Fraud Control Unit. The Commonwealth’s right of access to provider agencies and records shall survive any termination of the provider agreement;

13. Disclose, as requested by DMAS, all financial, beneficial, ownership, equity, surety, or other interests in any and all firms, corporations, partnerships, associations, business enterprises, joint ventures, agencies, institutions, or other legal entities providing any form of health care services to recipients of Medicaid;

14. Pursuant to 42 CFR Part 431, Subpart F, 12VAC30-20-90, and any other applicable state or federal law, hold confidential and use for authorized DMAS’ purposes only all medical assistance information regarding clients served. A provider shall disclose information in his possession only when the information is used in conjunction with a claim for health benefits or the data is necessary for the functioning of DMAS in conjunction with the cited laws. DMAS shall not disclose medical information to the public;

15. Notify DMAS of change of ownership, as defined in 42 CFR 489.18. When ownership of the provider changes, DMAS shall be notified at least 15 calendar days before the date of change;

16. For all facilities covered by §1616(e) of the Social Security Act in which home and community-based waiver services will be provided, be in compliance with applicable standards that meet the requirements for board and care facilities;

17. Suspected abuse or neglect. Pursuant to §§63.2-1509 and 63.2-1606 of the Code of Virginia, if a participating provider knows or suspects that a home and community-based waiver service client is being abused, neglected, or exploited, the party having knowledge or suspicion of the abuse, neglect, or exploitation shall report this immediately from first knowledge to the local DSS protective services worker, to DMAS, and to DMHMRSAS Offices of Licensing and Human Rights as applicable;

18. Adhere to the provider participation agreement and the DMAS provider service manual. In addition to compliance with the general conditions and requirements, all providers enrolled by DMAS shall adhere to the conditions of participation outlined in their individual provider participation agreements and in the DMAS provider manual.

D. Recipient choice of providers. The case manager must inform the client and family/caregiver of all available waiver providers in the community in which he desires services. The client and family/caregiver shall have the option of selecting the provider of his choice from among those providers who are able to meet his needs. A client’s case manager shall not be the direct staff person or immediate supervisor of a staff person who provides CMH waiver services for the client.

E. Review of provider participation standards and renewal of contracts. DMAS is responsible for assuring continued adherence to provider participation standards. DMAS shall conduct ongoing monitoring of compliance with provider participation standards and DMAS policies and periodically recertify each provider for participation agreement renewal with DMAS to provide home and community-based waiver services. A provider’s noncompliance with DMAS policies and procedures, as required in the provider’s participation agreement, may result in a written request from DMAS for a corrective action plan that details the steps the provider must take and the length of time permitted to achieve full compliance with the plan to correct the deficiencies that have been cited.

F. Termination of provider participation. A participating provider may voluntarily terminate his participation in Medicaid by providing 30 days’ written notification. DMAS may terminate at-will a provider’s participation agreement on 30 days’ written notice as specified in the DMAS participation agreement. DMAS may also immediately terminate a provider’s participation agreement in the event of a breach of the contract by the provider as specified in the DMAS participation agreement and also if the provider is no longer eligible to participate in the program. Such action precludes further payment by DMAS for services provided to clients subsequent to the date of termination.

G. Reconsideration of adverse actions. A provider shall have the right to appeal adverse action taken by DMAS to the extent such action is appealable under the Administrative Process Act (§2.2-4000 et seq. of the Code of Virginia). Unless otherwise provided by law, adverse action includes, but shall not be limited to, termination of the provider participation agreement by DMAS and retraction of payments from the provider by DMAS for noncompliance with applicable law, regulation, policy, or procedure. All disputes regarding provider reimbursement or termination of the agreement by DMAS for any reason shall be resolved through administrative proceedings conducted at the office of DMAS in Richmond, Virginia, unless otherwise provided by law. These administrative proceedings and judicial review of such administrative proceedings shall be conducted pursuant to the Virginia Administrative Process Act (§2.2-4000 et seq. of the Code of Virginia), the State Plan for Medical Assistance provided for in §32.1-325 of the Code of Virginia, and duly promulgated regulations. Court review of final agency determinations concerning provider reimbursement shall be made in accordance with the Administrative Process Act.

H. Provider appeals shall be considered pursuant to 12VAC30-10-1000 and 12VAC30-20-500 through 12VAC30-20-560.

I. It is the responsibility of the case management provider to notify DMAS, in writing, when any of the following circumstances or events occurs:

1. Home and community-based waiver services are implemented;

2. A client dies;

3. A client is discharged from all waiver services;

4. Any other circumstances (including hospitalization) that cause home and community-based waiver services to cease or be interrupted for more than 30 days; or

5. A selection by the client of a different provider of case management services.

J. Changes or termination of services. The case manager shall authorize changes to a client’s CSP based on the recommendations of the service provider and approval by the client or family/caregiver, as appropriate. Providers of direct service are responsible for modifying their ISP with the involvement of the client and family/caregiver and submitting ISPs to the case manager any time there is a change in the client’s condition or circumstances that may warrant a change in the amount or type of service rendered. The case manager will review the need for a change and may recommend a change to the CSP and submit this change to the DMAS-contracted preauthorization entity. The preauthorization entity will review and approve, deny, or pend for additional information the requested change to the client’s CSP, and communicate this to the case manager.  

K. In the case of reduction, termination, suspension or denial of home and community-based waiver services by the preauthorization contractor or DMAS staff, clients shall be notified in writing of their appeal rights by the case manager pursuant to 12VAC30-110. The case manager shall have the responsibility to identify those clients who no longer meet the level-of-care criteria or for whom home and community-based waiver services are no longer an appropriate alternative to residential placement. All CSPs are subject to approval by the Medicaid agency.

L. Termination of a provider participation agreement upon conviction of a felony. Section 32.1-325 of the Code of Virginia mandates that "any such Medicaid agreement or contract shall terminate upon conviction of the provider of a felony." A provider convicted of a felony in Virginia or in any other of the 50 states or Washington, D.C., must, within 30 days, notify the Medicaid Program of this conviction and relinquish its provider participation agreement. Reinstatement will be contingent upon provisions of state law. In addition, termination of a provider participation agreement will occur as may be required for federal financial participation.

M. Changes or termination of care. It is the DMAS staff’s responsibility to authorize any changes to a client’s CSP based on the recommendations of the case manager. Participating providers providing direct service are responsible for modifying the ISP if the client/family/caregiver agrees. The provider must submit the ISP to the case manager any time there is a change in the client’s condition or circumstances that may warrant a change in the amount or type of service rendered. The case manager must review the need for a change and will sign the ISP if he agrees to the changes. The case manager must submit the revised CSP to the DMAS staff to receive approval for that change. DMAS staff has the final authority to approve or deny the requested change.

1. Nonemergency termination of home and community-based care services by the participating provider. The participating provider must give the client and case manager 10 business days’ written notification of the intent to terminate services. The letter must provide the reasons for and the effective date of the termination. The effective date of services termination must be at least 10 days from the date of the termination notification letter. The client is not eligible for appeal rights in this situation and may pursue services from another provider.

2. Emergency termination of home and community-based care services by the participating provider. In an emergency situation when the health and safety of the client or provider agency personnel is endangered, the case manager, DMAS and the DMHMRSAS Offices of Licensing and Human Rights must be notified prior to termination of services. The 10-business day written notification period shall not be required. If appropriate, the local DSS protective services unit must be notified immediately.

3. DMAS termination of eligibility to receive home and community-based care services. DMAS has the ultimate responsibility for assuring appropriate placement of the client in home and community-based care services and the authority to terminate such services to the client for the following reasons:

a. The client no longer meets the institutional level-of-care criteria;

b. The client’s environment does not provide for his health, safety, and welfare; or

c. An appropriate and cost-effective CSP cannot be developed.

N. Documentation requirements.

1. Records of minors shall be kept for at least six years after such minor has reached the age of 18 years. The case manager must retain the following documentation for quality management review by DMAS for a period of not less than six years from each client’s last date of service or as provided by applicable state or federal laws, whichever period is longer.

a. The comprehensive assessment and all CSPs completed for the client;

b. All ISPs from every provider rendering waiver services to the client;

c. All supporting documentation related to any change in the ISP;

d. All related communication with the client, family/caregiver, consultants, providers, the screening entity, DMAS, DMHMRSAS, CSA, DSS and others involved in the care of the client; and

e. An ongoing log that documents all contacts made by the case manager related to the client.

2. Quality management review of client-specific documentation must be conducted by DMAS staff. This documentation must contain, up to and including the last date of service, all of the following:

a. All assessments and reassessments;

b. All ISP’s developed for that client and the written reviews;

c. Documentation of the date services were rendered and the amount and type of services rendered;

d. Appropriate data, contact notes or progress notes reflecting a client’s status and, as appropriate, progress or lack of progress toward the goals on the ISP; and

e. Any documentation to support that services provided are appropriate and necessary to maintain the client in the home and in the community.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. December 1, 2007.

12VAC30-135-170. (Reserved.)

12VAC30-135-180. Agency-directed companion services.

A. Service description. Companion services provide assistance with skill development and with understanding family interaction, behavioral interventions for support and safety, nonmedical care, nonmedical transportation, community integration, and rewarding appropriate behaviors. These include, but are not limited to, nonmedical care, socialization, or support to a client. Companions may assist or support the individual with such tasks as meal preparation, community access and activities, laundry and shopping, but companions do not perform these activities as discrete services. This service is provided in accordance with a therapeutic goal in the ISP and is not purely diversional in nature.

B. Criteria. In order to qualify for companion services, the client shall have demonstrated a need for assistance with IADLs, light housekeeping, community access, reminders for medication self-administration, or support to assure safety.

1. The inclusion of companion services in the ISP is appropriate only when the client cannot be left alone at any time due to the SED. The provision of companion services does not entail hands-on care.

2. Companion services shall not be covered if required only because the client does not have a telephone in the home or because the client does not speak English.

3. There must be a clear and present danger to the client as a result of being left unsupervised. Companion services cannot be authorized for clients whose only need for such services is for assistance exiting the home in the event of an emergency.

C. Service units and service limitations.

1. The amount of companion services time included in the ISP must be no more than is necessary to prevent the deterioration or injury to the client. In no event may the amount of time relegated solely to companion care on the ISP exceed eight hours per day, either separately or in any combination of CD and agency-directed companion services.

2. The hours authorized are based on individual need. No more than three unrelated clients who are receiving waiver services and live in the same home are permitted to share the authorized work hours of the same companion.

3. Companion care will be authorized for family members/caregivers to sleep either during the day or during the night when the client cannot be left alone at any time due to his condition. Companion services must be necessary to ensure the client’s safety if he cannot be left unsupervised due to health and safety concerns.

4. Companion services can be authorized when no one else is in the home who is competent to monitor the client for safety.

D. Provider requirements. In addition to meeting the general conditions and requirements for home and community-based participating providers as specified in 12VAC30-135-120 and 12VAC30-135-160, companion service providers must meet the following qualifications:

1. Providers must either be licensed by DMHMRSAS as (i) a residential service provider, (ii) supportive in-home residential service provider; (iii) day support service provider; or (iv) respite service provider; or meet the DMAS criteria to be a personal care/respite services provider.

2. Companions will be employees of providers that have provider participation agreements with DMAS to provide companion services. Providers are required to have a companion services supervisor to monitor companion services. The supervisor must be at least a QMHP.

3. The supervisor must conduct an initial home visit prior to initiating companion services to document the efficacy and appropriateness of services and to establish an ISP for the client. The supervisor must provide follow-up home visits to monitor the provision of services at a minimum of every three months or as often as needed. The client must be reassessed for services annually.

4. Required documentation in the client’s record. The provider must maintain a record of each client receiving companion services. At a minimum these records must contain:

a. An initial assessment completed prior to the date services are initiated and subsequent reassessments and changes to the ISP;

b. An ISP containing the following elements:

(1) The client’s strengths, desired outcomes, required or desired supports, or both;

(2) The services to be rendered and the schedule of services to accomplish the desired outcomes;

c. Documentation that the ISP goals, objectives, and activities have been reviewed by the provider quarterly, annually, and more often as needed, modified as appropriate, and the results of these reviews submitted to the case manager. For the annual review and in cases where the ISP is modified, the ISP must be reviewed with the client and family/caregiver.

d. All correspondence to the client, family/caregiver, case manager, DMAS, and DMHMRSAS;

e. Contacts made with family/caregiver, physicians, formal and informal service providers, and others involved in the care of the child;

f. The companion services supervisor must document in the client’s record in a summary note following significant contacts with the companion and home visits with the client that occur at least quarterly:

(1) Whether companion services continue to be appropriate;

(2) Whether the plan is adequate to meet the client’s needs or changes are indicated in the plan;

(3) The client and family/caregiver’s satisfaction with the service;

(4) The presence or absence of the companion during the supervisor’s visit;

(5) Any suspected abuse, neglect, or exploitation and to whom it was reported; and

(6) Any hospitalization or change in medical condition, functioning, or cognitive status.

g. In addition to the above requirements, the companion record must contain:

(1) The specific services delivered to the client by the companion, dated the day of service delivery, and the client’s responses;

(2) The companion''s arrival and departure times;

(3) The companion''s weekly comments or observations about the client to include observations of the client’s physical and emotional condition, daily activities, and responses to services rendered; and

(4) The weekly signature of the companion, or parent/caregiver, as appropriate, recorded and dated on the last day of service delivery for any given week to verify that companion services during that week have been rendered.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. December 1, 2007.

12VAC30-135-190. (Reserved.)

12VAC30-135-200. Agency-directed respite services.

A. Service description.

1. Respite services means services specifically designed to provide a temporary but periodic or routine relief to the primary unpaid caregiver of a client who is in need of specialized supervision due to a SED. Respite services include assistance with or monitoring of personal hygiene, nutritional support, safety, and environmental maintenance authorized as either episodic, temporary relief, or as a routine periodic relief of the caregiver.

2. Respite services do not include either practical or professional nursing services or those practices regulated in Chapters 30 (§54.1-3000 et seq.) and 34 (§54.1-3400 et seq.) of Title 54.1 of the Code of Virginia, as appropriate. This service does not include skilled nursing services with the exception of skilled nursing tasks that may be delegated pursuant to 18VAC90-20-420 through 18VAC90-20-460.

B. Criteria.

1. Respite services may only be offered to clients who have an unpaid primary caregiver living in the home who requires temporary relief to avoid institutionalization of the client. Respite services are designed to focus on the need of the caregiver for temporary relief.

2. Respite services are supports for the family or other unpaid primary caregiver of a client. These services are furnished on a short-term basis because of the absence or need for relief of those unpaid caregivers normally providing the care for the clients.

C. Service units and service limitations.

1. Respite services shall be limited to a maximum of 720 hours per calendar year. Clients who are receiving services through both the agency-directed and CD models shall not exceed 720 hours per calendar year combined.

2. The unit of service is one hour.

D. Provider requirements. In addition to meeting the general conditions and requirements for home and community-based participating providers as specified in 12VAC30-135-120 and 12VAC30-135-160, respite services providers must meet additional provider requirements:

1. Services shall be provided by:

a. A DMAS respite services provider; a DMHMRSAS-licensed residential services provider; or by a DMHMRSAS-licensed respite services provider or a DSS-approved foster care home-for-children provider.

b. For DMAS-enrolled respite services providers, the provider must employ or subcontract with a QMHP or LMHP to supervise all assistants. The supervisor must meet DMAS qualifications.

2. The QMHP/LMHP supervisor must make a home visit to conduct an initial assessment prior to the start of services for all clients requesting respite services. The supervisor must also perform any subsequent reassessments or changes to the ISP.

3. The QMHP/LMHP supervisor must make supervisory home visits as often as needed to ensure both quality and appropriateness of services. The minimum frequency of these visits is every 30 to 90 days.

a. When respite services are received on a routine basis, the minimum acceptable frequency of these supervisory visits shall be every 30 to 90 days, depending on the needs of the client.

b. When respite services are not received on a routine basis, but are episodic in nature, the supervisor is not required to conduct a supervisory visit every 30 to 90 days. Instead, the QMHP/LMHP supervisor must conduct the initial home visit with the respite care assistant immediately preceding the start of services and make a second home visit within the respite services period.

4. Based on continuing evaluations of the assistant’s performance and client’s needs, the QMHP/LMHP supervisor shall identify any gaps in the assistant’s ability to function competently and shall provide training as indicated.

5 The QMHP/LMHP supervisor must document in a summary note:

a. Whether respite services continue to be appropriate;

b. Whether the ISP is adequate to meet the client’s needs or if changes need to be made;

c. The client’s and family/caregiver’s satisfaction with the service;

d. Any hospitalization or change in medical condition or functioning status;

e. Other services received and the amount; and

f. The presence or absence of the assistant in the home during the visit.

6. Qualification of assistants. The assistant must complete a training curriculum consistent with DMAS requirements. Prior to assigning an assistant to a client, the provider must obtain documentation that the assistant has satisfactorily completed a training program consistent with DMAS’ requirements. DMAS requirements may be met in one of two ways:

a. Registration as a certified nurse aide; or

b. Graduation from an approved educational curriculum that offers certificates qualifying the student as a nursing assistant, home health aide, or meeting the paraprofessional criteria as established by 12VAC30-50-226.

E. Required documentation for the client’s records. The provider must maintain all records of each client receiving services. These records must be separated from those of other nonwaiver services, such as home health services. These records will be reviewed periodically by DMAS staff. At a minimum these records must contain:

1. An initial assessment completed by the QMHP/LMHP supervisor prior to or on the date services are initiated;

2. Reassessments and any changes to the ISP made during the provision of services by the supervisor.

3. The most recent ISP and supporting documentaion that contains, at a minimum, the following elements:

a. The client’s strengths, desired outcomes, and required or desired supports;

b. The client’s and family’s/caregiver’s goals and objectives to meet the identified outcomes;

c. Services to be rendered and the frequency of services to accomplish the goals and objectives; and

d. The provider staff responsible for the overall coordination and integration of the services specified in the ISP.

4. The ISP goals, objectives, and activities must be reviewed by the supervisor quarterly, annually, and more often as needed and modified as appropriate. The results of these reviews must be submitted to the case manager. For the annual review and in cases where the ISP is modified, the ISP must be reviewed with the client and family/caregiver.

5. The QMHP/LMHP supervisor’s notes recorded and dated during significant contacts with the respite services assistant and during supervisory visits to the client’s home. The written summary of the supervision visits must include:

a. Whether services continue to be appropriate and whether the ISP is adequate to meet the needs or if changes are indicated in the ISP;

b. Any suspected abuse, neglect, or exploitation and to whom it was reported;

c. Any special tasks performed by the assistant and the assistant’s qualifications to perform these tasks;

d. The client’s and family/caregiver’s satisfaction with the service;

e. Any hospitalization or change in medical condition or functioning status;

f. Other services received and their amount; and

g. The presence or absence of the assistant in the home during the supervisor’s visit.

6. All correspondence to the client, family/caregiver, case manager, DMAS, DMHMRSAS, and CSA;

7. Significant contacts made with the client, family/caregivers, physicians, DMAS and others involved in the care of the client;

8. The assistant record must contain:

a. The specific services delivered to the client by the assistant, dated the day of service delivery, and the client’s responses;

b. The assistant’s arrival and departure times;

c. The assistant’s weekly comments or observations about the client to include observations of the client’s physical and emotional condition, daily activities, and responses to services rendered; and

d. The assistant’s, client’s and family/caregiver’s weekly signatures with dates recorded on the last day of service delivery for any given week to verify that services during that week have been rendered.

e. Signatures, times, and dates shall not be placed on the assistant record prior to the last date of the week that the services are delivered.

9. All DMAS quality management review forms.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. December 1, 2007.

12VAC30-135-210. (Reserved.)

12VAC30-135-220. Consumer-directed companion and respite services.

A. Companion services.

1. Service description. Companion services provide assistance with skill development and with understanding family interaction, behavioral interventions for support and safety, nonmedical care, nonmedical transportation, community integration, and rewarding appropriate behaviors. This service is available through both a consumer-directed (CD) and agency-directed delivery approach and shall not exceed eight hours in one day. These services include, but are not limited to, nonmedical care, socialization, or support to a client as well as supervision or monitoring to those clients who require the physical presence of an aide to ensure their safety during times when no other supportive individuals are available. This service is provided in accordance with a therapeutic goal in the ISP and is not purely diversional in nature.

2. Criteria.

a. The inclusion of companion services in the ISP is appropriate only when the client cannot be left alone at any time due to the SED. The provision of companion services does not entail hands-on care.

b. Companion services shall not be covered if required only because the client does not have a telephone in the home or because the client does not speak English.

c. There must be a clear and present danger to the client as a result of being left unsupervised. Companion services cannot be authorized for clients whose only need for companion services is for assistance exiting the home in the event of an emergency.

3. Service units and service limitations.

a. The amount of companion service time included in the ISP must be no more than eight hours per day, either separately or in any combination of CD or agency-directed companion services.

b. The hours authorized are based on individual need. No more than three unrelated individuals who are receiving waiver services and live in the same home are permitted to share the authorized work hours of the same companion.

c. Companion services may be authorized for family/caregivers to sleep either during the day or during the night when the client cannot be left alone at any time due to the client’s condition. Companion aide services must be necessary to ensure the client’s safety if the client cannot be left unsupervised due to health and safety concerns.

d. Companion services can be authorized when no one else is in the home who is competent to monitor the client for safety.

4. Provider requirements. In addition to meeting the general conditions and requirements for home and community-based participating providers as specified in 12VAC30-135-120 and 12VAC30-135-160, companion service providers must meet the following qualifications:

a. General companion qualifications. Companions must meet the following requirements:

(1) Be at least 18 years of age;

(2) Have the required skills to perform CD services as specified in the client’s ISP;

(3) Possess basic reading, writing, and math skills;

(4) Be capable of following a care plan with minimal supervision;

(5) Submit to a criminal history record check within 15 days from the date of employment and, if the client is a minor, the Child Protective Services Central Registry. The companion will not be compensated for services provided to the client if the records check verifies the companion has been convicted of crimes described in §32.1-162.9:1 or 37.2-416 of the Code of Virginia; or if the companion has a complaint confirmed by the DSS Child Protective Services Central Registry;

(6) Possess a valid social security number;

(7) Be willing to attend training at the client’s and family/caregiver’s request;

(8) Receive an annual tuberculosis (TB) screening; and

(9) Understand and agree to comply with the DMAS CMH waiver requirements as described in DMAS guidance documents.

b. Companions shall not be spouses, parents or caregivers. Payment will not be made for services furnished by other family members unless there is objective written documentation as to why there are no other providers available to provide the care. Medicaid-reimbursed companion services shall not be provided by adult foster care providers or any other paid (regardless of the payment source) caregivers for a client residing in that home.

c. Family/caregivers who are reimbursed to provide companion services must meet the companion qualifications stated above.

d. Retention, hiring, and substitution of companions. Upon the client’s request, the CD services facilitator shall provide the client or family/caregiver with a list of persons on the assistant registry who can provide temporary assistance until the assistant returns or the client is able to select and hire a new assistant. If a client or family/legal guardian is consistently unable to hire and retain the employment of an assistant to provide CD companion services, the services facilitator must contact the case manager and DMAS to transfer the client, at the client’s choice, to a provider that provides Medicaid-funded agency-directed companion services. The CD services facilitator will make arrangements with the case manager to have the client transferred.

B. Respite services.

1. Service description. Respite services include assistance with or monitoring of personal hygiene, nutritional support, safety, and environmental maintenance authorized as either episodic, temporary relief, or as a routine periodic relief of the caregiver. For the purposes of this section, an assistant refers to the individual providing CD respite.

2. Criteria.

a. CD respite services may only be offered to clients who have a primary unpaid caregiver living in the home who requires temporary relief to avoid institutionalization of the client, and it is designed to focus on the need of the caregiver for temporary relief.

b. The inclusion of respite services in the ISP is appropriate only when the client cannot be left unsupervised due to the mental health condition at any time.

3. Service units and service limitations.

a. CD respite services are limited to a maximum of 720 hours per calendar year. Clients who are receiving services through both the agency-directed and CD models shall not exceed 720 hours per calendar year combined.

b. Clients can receive CD respite services and in-home residential support services in their CSPs but cannot receive these services simultaneously.

c. For CD respite services, clients and family/legal guardian, as appropriate, will hire their own assistants and manage and supervise the assistant’s performance.

4. Provider requirements.

a. The assistant must meet the following requirements:

(1) Be at least 18 years of age;

(2) Have the required skills to perform CD services as specified in the client’s ISP;

(3) Possess basic reading, writing and math skills;

(4) Be capable of following a care plan with minimal supervision;

(5) Submit to a criminal history record check within 15 days from the date of employment, and if the client is a minor, the Child Protective Services Central Registry. The assistant will not be compensated for services provided to the client if the records check verifies the assistant has been convicted of crimes described in §32.1-162.9:1 or 37.2-416 of the Code of Virginia or if the assistant has a complaint confirmed by the DSS Child Protective Services Central Registry;

(6) Possess a valid social security number;

(7) Be willing to attend training at the client’s and family/caregiver’s request;

(8) Receive periodic TB screening; and

(9) Understand and agree to comply with the DMAS CMH waiver requirements;

b. Assistants cannot be spouses, parents of minor children, or legally responsible relatives. Payment will not be made for services furnished by other family members unless there is objective written documentation as to why there are no other providers available to provide the care.

c. Family/caregivers who are reimbursed to provide respite services must meet the assistant qualifications.

d. Retention, hiring, and substitution of assistants. Upon the client’s request, the CD services facilitation provider shall provide the client or family/legal guardian with a list of persons on the assistant registry who can provide temporary assistance until the assistant returns or the client is able to select and hire a new assistant. If a client is consistently unable to hire and retain the employment of an assistant to provide CD respite services, the CD services facilitator must contact the case manager and DMAS to transfer the client, at the client’s choice, to a provider that provides Medicaid-funded agency-directed respite services. The CD services facilitator will make arrangements with the case manager to have the client transferred.

C. Service facilitation.

1. Clients choosing the CD option must receive support from a CD services facilitator and meet requirements for consumer direction as described in these regulations.

2. DMAS shall contract for the services of a Fiscal Management Service agent for CD companion and respite services. The FMS agent will be reimbursed by DMAS to perform certain tasks as an agent for the client/family/caregiver/employer who is receiving CD services. The FMS agent will handle the responsibilities for the client/family/caregiver/employer for employment taxes. The FMS agent will seek and obtain all necessary authorizations and approvals of the Internal Revenue Services in order to fulfill all of these duties.

3. If a client is unable to direct his own care or is under 18 years of age, a family/legal guardian may serve as the employer on behalf of the client. Specific employer duties include checking of references of assistants/companions, determining that assistants/companions meet basic qualifications, training assistants/companions, supervising the assistant’s/companion’s performance, and submitting timesheets to the FMS agent on a consistent and timely basis. There must be a back-up plan in case the assistant/companion does not show up for work as expected or terminates employment without prior notice. This is the responsibility of the client or family/legal guardian to establish.

4. Clients or family/legal guardians, as appropriate, choosing the CD model of service delivery must receive support from a CD services facilitator. This is not a separate waiver service, but is required in conjunction with CD respite and companion services. The CD services facilitator is responsible for assessing the client’s particular needs for a requested CD service, assisting in the development of the ISP, providing training to the family/legal guardian on his responsibilities as an employer, and providing ongoing support of the CD model of services. The CD services facilitator cannot be the client, the client’s case manager, direct service provider, spouse, parent or legally responsible party of the client who is a minor child, or a family/legal guardian employing the assistant/companion. If a client enrolled in CD services has a lapse in services for more than 90 consecutive days, DMAS must be notified and the CD services will be discontinued.

5. Either DMAS or its contractor shall provide the FMS for CD companion and respite services. The FMS agent will be reimbursed by DMAS to perform certain tasks as an agent for the client/employer who is receiving CD services. The FMS agent will handle the responsibilities of employment taxes for the client. The FMS agent will seek and obtain all necessary authorizations and approvals of the Internal Revenue Services in order to fulfill all of these duties.

6. CD services facilitator qualifications. In addition to meeting the general conditions and requirements for home and community-based services participating providers as specified in 12VAC30-135-120 and 12VAC30-135-160, the CD services facilitator must meet the following qualifications:

a. To be enrolled as a Medicaid CD services facilitator and maintain provider status, the CD services facilitator must operate from a physical business office and employ sufficient qualified staff to perform the needed ISP development and monitoring, reassessments, service coordination, and support activities as required. In addition, the CD services facilitator must have the ability to maintain and retain business and professional records sufficient to document fully and accurately the nature, scope, and details of the services provided.

b. It is preferred that employees of the CD services facilitator possess a minimum of an undergraduate degree in a human services field or be a QMHP. In addition, it is preferable that the CD services facilitator have two years of satisfactory experience in the human services field working with persons with SED. The CD services facilitator must possess a combination of work experience and relevant education that indicates possession of the following knowledge, skills, and abilities. Such knowledge, skills and abilities must be documented on the application form, found in supporting documentation, or be observed during the job interview. Observations during the interview must be documented. The knowledge, skills, and abilities include:

(1) Knowledge of:

(a) Types of functional limitations and health problems that may occur in clients with SED, or clients with other disabilities, as well as strategies to reduce limitations and health problems;

(b) Equipment and environmental modifications that may be required by clients with SED that reduce the need for human help and improve safety;

(c) Community-based and other services, including PRTF placement criteria, Medicaid waiver services, and other federal, state, and local resources that provide respite and companion services;

(d) CMH Waiver requirements, as well as the administrative duties for which the services facilitator will be responsible;

(e) CMH Waiver requirements, as well as the administrative duties for which the client and family/caregiver will be responsible;

(f) Conducting assessments (including environmental, psychosocial, health, and functional factors) and their uses in care planning;

(g) Interviewing techniques;

(h) The client’s and family/legal guardian’s right to make decisions about, direct the provisions of, and control his CD respite and companion services, including hiring, training, managing, approving time sheets, and firing an assistant/companion;

(i) The principles of human behavior and interpersonal relationships; and

(j) General principles of record documentation.

(2) Skills in:

(a) Negotiating with clients, family/caregivers and service providers;

(b) Assessing, supporting, observing, recording, and reporting behaviors;

(c) Identifying, developing, or providing services to clients with SED; and

(d) Identifying services within the established services system to meet the client’s needs.

(3) Abilities to:

(a) Report findings of the assessment or onsite visit, either in writing or an alternative format for clients who have visual impairments;

(b) Demonstrate a positive regard for clients and their families;

(c) Be persistent and remain objective;

(d) Work independently, performing position duties under general supervision;

(e) Communicate effectively, orally and in writing; and

(f) Develop a rapport and communicate with persons from diverse cultural backgrounds.

c. If the CD services facilitator is not a QMHP, the CD services facilitator must have QMHP consulting services available, either by a staffing arrangement or through a contracted consulting arrangement. The QMHP consultant is to be available as needed to consult with clients and CD services facilitators on issues related to the needs of the client.

7. Initiation of services and service monitoring.

a. The CD services facilitator must make an initial comprehensive home visit to collaborate with the client and family/caregiver to identify needs, assist in the development of the ISP with the client and provide employee management training. The initial comprehensive home visit is done only once upon the client’s entry into the CD model of service regardless of the number or type of CD services that a client chooses to receive. If a client changes CD services facilitators, the new CD services facilitator must complete and bill for a reassessment visit in lieu of an initial comprehensive visit.

b. After the initial visit, the CD services facilitator will periodically review the utilization of companion services at a minimum of every six months or, for respite services, either every six months or upon the use of 300 respite service hours, whichever comes first.

c. A reassessment of the client’s level-of-care will occur six months after initial entry into the program, and subsequent reevaluations will occur at a minimum of every six months. During visits to the client’s home, the CD services facilitator must observe, evaluate, and consult with the client and family/caregiver and document the adequacy and appropriateness of CD services with regard to the client’s current functioning and cognitive status, medical, and social needs. The CD services facilitator’s summary must include, but not necessarily be limited to:

(1) Whether CD respite services continue to be appropriate and medically necessary to prevent institutionalization;

(2) Whether the service is adequate to meet the client’s needs;

(3) Any special tasks performed by the assistant/companion and the assistant’s/companion’s qualifications to perform these tasks;

(4) Client’s or family/caregiver’s satisfaction with the service;

(5) Hospitalization or change in medical condition, functioning, or cognitive status;

(6) Other services received and their amount; and

(7) The presence or absence of the companion/assistant in the home during the CD services facilitator''s visit.

d. A face-to-face meeting with the client must be conducted at least every six months to reassess the client’s needs and to ensure appropriateness of any CD services received by the client.

e. The CD services facilitator must be available to the client and family/caregiver by telephone.

f. The CD services facilitator must submit a criminal record check pertaining to the assistant/companion on behalf of the client and report findings of the criminal record check to the client and the program’s FMS agent. If the client is a minor, the assistant/companion must also be screened through the DSS Child Protective Services Central Registry. Assistants/companions will not be reimbursed for services provided to the client effective the date that the criminal record check confirms an assistant/companion was convicted of a barrier crime or if the assistant/companion has a founded complaint on record in the DSS Child Protective Services Central Registry. The criminal record check and DSS Child Protective Services Central Registry finding must be requested by the CD services facilitator within 15 calendar days of employment. The services facilitator must maintain evidence that a criminal record check was obtained and must make such evidence available for DMAS review.

g. The CD services facilitator shall review and verify bi-weekly timesheets signed by the family/caregiver and the assistant/companion during the face-to-face visits or more often as needed to ensure that the number of ISP-approved hours is not exceeded. If discrepancies are identified, the CD services facilitator must discuss these with the client to resolve discrepancies and must notify the FMS agent. If the client is consistently identified as having discrepancies in his timesheets, the CD services facilitator must contact the case manager to resolve the situation. The CD services facilitator cannot verify timesheets for assistants/companions who have been convicted of a barrier crime or who have a founded complaint on record in the DSS Child Protective Services Registry and must notify the FMS agent.

h. The CD services facilitator must maintain records of each client as described in 12VAC30-135-120 and 12VAC30-135-160.

i. If a client/family/legal guardian is consistently unable to hire and retain the employment of an assistant/companion to provide CD respite or companion services, the CD services facilitator will make arrangements with the case manager to have the services transferred to an agency-directed services provider or to discuss with the client/family/caregiver other service options.

j. The family/legal guardian or client, as appropriate, must hire and train the assistants or companions and supervise the assistant’s or companion’s performance. The hours authorized are based on individual need.

8. Responsibilities as employer. The client or family/legal guardian, as appropriate, shall be the employer in this service and responsible for hiring, training, supervising, and firing assistants and companions. Specific duties include checking references of assistants/companions, determining that assistants/companions meet basic qualifications, training assistants/companions, supervising the assistant’s/companion’s performance, and submitting timesheets to the CD services facilitator and FMS agent on a consistent and timely basis. The client must have an emergency back-up plan in case the assistant/companion does not show up for work as expected or terminates employment without prior notice.

9. Required documentation in client’s records. The CD services facilitator must maintain all records of each client. At a minimum these records must contain:

a. All copies of the ISP and all supporting documentation.

b. All DMAS quality management review forms.

c. CD services facilitator’s notes contemporaneously recorded and dated during any contacts with the client and family/caregiver and during visits to the client’s home.

d. All correspondence to the client, family/caregiver and to DMAS.

e. Reassessments made during the provision of services.

f. Records of contacts made with family/caregivers, physicians, DMAS, formal and informal service providers, and others involved in the care of the child.

g. All training provided to the assistant/companion or assistants/companions on behalf of the client.

h. All management training provided to the client or family/caregiver including the client’s or family/caregiver’s responsibility for the accuracy of the timesheets.

i. All documents signed by the client or family/caregiver that acknowledge the responsibilities of the services.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. December 1, 2007.

12VAC30-135-230. (Reserved.)

12VAC30-135-240. Community transition services.

A. Service description.

Community transition services are provided to individuals who are leaving the PRTF and have chosen to receive services in the community. Community transition services include assessment of the child and family; assistance with meeting the requirements of waiver enrollment; referral for Medicaid eligibility; developing a community plan of care in coordination with the family, CSA (if involved), and other involved parties; identifying community service providers; and monitoring the initial transition to the community. Community transition services do not include monthly rental or mortgage expense; food, regular utility charges; and/or household appliances or items that are intended for purely diversional/recreational purposes.

Community transition services ensure the development, coordination, implementation, monitoring, and modification of comprehensive service plans; link recipients with appropriate community resources and supports; coordinate service providers; and monitor quality of care.

Community transition services may be provided in the PRTF, in the home, school or other community locations.

Community transition services may be provided up to three months prior to discharge from the PRTF and one month after discharge. The cost of community transition services is considered to be incurred and billable when the client leaves the PRTF and enters the Children’s Mental Health Waiver.

B. Criteria. In order to qualify for these services, the client must be a resident of the PRTF and also have been identified as a possible participant in the Children’s Mental Health Waiver.

C. Service units and service limitations. The unit of service shall be 15 minutes with a maximum of 80 units for each admission to the Children’s Mental Health Waiver.

Services provided must be documented in records maintained by the community transition services provider. Documentation may be required to be submitted to DMAS.

D. Provider requirements. In addition to meeting the general conditions and requirements for home and community-based participating providers as specified in 12VAC30-135-120 and 12VAC30-135-160, professionals rendering community transition services must be DMAS-enrolled providers of treatment foster care case management, DMAS-enrolled providers of mental health case management services or be local CSA coordinators or FAPT members who meet the knowledge, skills, and abilities established for mental health case managers.

E. The following documentation is required:

1. A comprehensive services plan that contains at a minimum, the following elements:

a. Identifying information: client’s name and Medicaid number; provider name and provider number; responsible person and telephone number; effective dates for supporting documentation; and semi-annual review dates, if applicable;

b. Identified services, provider names and individual service plans;

c. Targeted objectives, time frames, and expected outcomes.

2. Ongoing documentation of all contacts. All notes must include:

a. Specific details of the activities conducted;

b. Dates, locations, and times of service delivery;

c. CSP objectives addressed;

d. Services delivered as planned or modified;

e. Effectiveness of the strategies and client’s and family/caregiver’s satisfaction with service;

f. Client status; and

g. Outcomes and effectiveness of the comprehensive services plan.

F. When transition coordination services are completed, a final CSP must be discussed and forwarded to the ongoing case manager before the end of transition coordination. The transition services coordination provider must include:

1. Strategies utilized;

2. Objectives met;

3. Unresolved issues; and

4. Consultant recommendations.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. December 1, 2007.

12VAC30-135-250. (Reserved.)

12VAC30-135-260. Environmental modifications.

A. Service description. Environmental modifications shall be defined as those physical adaptations to the home or to a vehicle, included in the client’s ISP, that are necessary to ensure the health, welfare, and safety of the client, or that enable the client to function with greater independence in the home and without which the client would require continued institutionalization. Such adaptations include items to ensure the safety of the client, family/caregiver and the community. Modifications can be made to an automotive vehicle only if it is the primary vehicle being used by the client.

B. Service units and service limitations. Environmental modifications shall be available to clients who are receiving at least one other waiver service. A maximum limit of $5,000 may be reimbursed per ISP year. Costs for environmental modifications shall not be carried over from ISP year to ISP year and must be pre-authorized by DMAS or the contracted preauthorization entity for each ISP year. Excluded from this service shall be those adaptations or improvements to the home that are of general utility and are not of direct medical or remedial benefit to the client, such as carpeting, roof repairs, central air conditioning, etc. Adaptations that add to the total square footage of the home are also excluded from this benefit. Modifications may not be used to bring a substandard dwelling up to minimum habitation standards. Also excluded are modifications that are reasonable accommodation requirements of the Americans with Disabilities Act, the Virginians with Disabilities Act, and the Rehabilitation Act. All services shall be provided in accordance with applicable state or local building codes.

C. Criteria. In order to qualify for these services, the client must have a demonstrated need for equipment or modifications of a remedial or medical benefit offered primarily in a client’s primary home, primary vehicle used by the client or for the client by the family/caregiver, to specifically improve the client’s personal functioning. This service shall encompass those items not otherwise covered in the State Plan for Medical Assistance or through another program.

D. Provider requirements. In addition to meeting the general conditions and requirements for home and community-based participating providers as specified in 12VAC30-135-120 and 12VAC30-135-160, environmental modifications must be provided in accordance with all applicable federal, state or local building codes and laws by providers who have a provider participation agreement with DMAS. The provider must submit information regarding environmental modifications to the case manager. The following are provider documentation requirements that must be included in the client’s record:

1. Supporting documentation that documents the need for the service, the process to obtain the service, and the time frame during which the services are to be provided;

2. Documentation of the time frame involved to complete the modification and the amount of services and supplies;

3. Any other relevant information regarding the modification;

4. Documentation of notification by the client and family/caregiver of satisfactory completion of the service; and

5. Instructions regarding any warranty, repairs, complaints, and servicing that may be needed.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. December 1, 2007.

12VAC30-135-270. (Reserved.)

12VAC30-135-280. Family/caregiver training.

A. Service description. Family or caregiver training is the provision of identified training and education related to SED, community integration, family dynamics, stress management, behavioral interventions, and mental health to the family/caregiver. For purposes of this service, "family" is defined as the persons who live with, provide care to or support a waiver client, and may include a spouse, children, relatives, a legal guardian, foster family, or in-laws. "Family" does not include individuals who are employed to care for the client. All family/caregiver training must be included in the client’s ISP.

B. Criteria. The need for the training and the content of the training in order to assist the family or caregivers with maintaining the client at home must be documented in the client’s ISP. The training must be necessary in order to improve the family or caregiver’s ability to provide care and support.

C. Service units and service limitations. Services are billed hourly and must be pre- authorized. Clients may receive up to 80 hours of family/caregiver training per ISP treatment year.

D. Provider requirements. In addition to meeting the general conditions and requirements for home and community-based care participating providers as specified in 12VAC30-135-120 and 12VAC30-135-160, providers must meet the following qualifications:

1. Family/caregiver training must be provided on an individual basis, in small groups or through seminars and conferences provided by Medicaid-approved or enrolled family and caregiver training providers;

2. Family/caregiver training must be provided by individuals with expertise who work for an agency with experience in or demonstrated knowledge of the training topic and who work for an agency or organization that has a provider participation agreement with DMAS to provide these services. Individuals must also have the appropriate licensure or certification as required for the specific professional field associated with the training area. Licensed professional counselors, licensed clinical social workers, licensed psychologists, licensed marriage and family therapists, and psychiatric clinical nurse specialists may enroll as individual practitioners with DMAS to provide family/caregiver training;

3. The family/caregiver training provider must submit documentation of all training to the case manager quarterly. This documentation must include:

a. All assessments and reassessments;

b. All supporting documentation developed for the client and the written reviews;

c. Documentation of the date services were rendered and the amount and type of services rendered; and

d. Any documentation to support that services provided are appropriate and necessary to maintain the client in the home and in the community.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. December 1, 2007.

12VAC30-135-290. (Reserved.)

12VAC30-135-300. In-home residential support services.

A. Service description.

1. The service shall be designed to enable clients qualifying for the CMH Waiver to live in their homes and shall include (i) training and assistance in or reinforcement of functional skills and appropriate behavior related to a client’s health and safety, personal care, ADLs, and use of community resources; (ii) assistance with medication management and monitoring the client’s health, nutrition, and physical condition; (iii) life skills training; and (iv) cognitive rehabilitation.

2. This service provides assistance or specialized supervision provided primarily in a client’s home or foster home to enable a client to acquire, retain, or improve the self-help, socialization, behaviors and adaptive skills necessary to reside successfully in home and community-based settings.

3. This service must be provided on a client-specific basis according to the ISP, supporting documentation, and service setting requirements.

4. Room and board and general supervision shall not be components of this service.

5. This service shall not be used solely to provide routine or emergency respite care for the family or caregivers with whom the client lives.

6. Medicaid reimbursement is available only for in-home residential support services provided when the client is present and when a qualified provider is providing the services.

B. Criteria.

1. All clients must meet the CMH Waiver criteria in order for Medicaid to reimburse for in-home residential support services. The client shall have a demonstrated need for supports to be provided by staff who are paid by the in-home residential support provider.

2. A functional assessment must be conducted to evaluate each client in his home environment and community settings.

3. The supporting documentation must indicate the necessary amount and type of activities required by the client, the schedule of residential support services, and the total number of projected hours per week of waiver reimbursed residential support.

4. Routine supervision/oversight of direct care staff. To provide additional assurance for the protection or preservation of a client’s health and safety, there are specific requirements for the supervision and oversight of direct care staff providing residential support as outlined below. All in-home residential support services must be provided under a DMHMRSAS license and include the following requirements:

a. An employee of the agency, typically by position, must be formally designated as the supervisor of each direct care staff person who is providing in-home residential support services.

b. The supervisor must have and document at least one supervisory contact per month with each staff person regarding service delivery and staff performance.

c. The supervisor must observe each staff person delivering services at least semi-annually. Staff performance and service delivery according to the ISP should be documented, along with evaluation and evidence of the client’s and family/caregiver’s satisfaction with service delivery by staff.

d. Providers of in-home residential supports must also have and document at least one monthly contact with the client and family/caregiver regarding satisfaction with services delivered by each staff person.

C. Service units and service limitations. In-home residential supports shall be reimbursed on an hourly basis for time the in-home residential support staff is working directly with the client. Total monthly billing cannot exceed the authorized amount in the ISP. The provider must maintain documentation of the date and times that services are provided, the specific services provided, and specific circumstances that prevented provision of all of the scheduled services, if applicable.

Service providers shall be reimbursed only for the amount and type of in-home residential support services included in the client’s approved ISP. Services will not be reimbursed for a continuous 24-hour period.

D. Provider requirements. In addition to meeting the general conditions and requirements for home and community-based care participating providers as specified in 12VAC30-135-120 and 12VAC30-135-160, each in-home residential support service provider must be licensed by DMHMRSAS as a provider of supportive residential services. The provider must also have training in mental health and appropriate interventions, strategies, and support methods for persons with SED.

1. The ISP and ongoing documentation must be consistent with licensing regulations.

2. Documentation must confirm attendance and the amount of time services were provided and provide specific information regarding the client’s response to various settings and supports as agreed to in the ISP objectives. Assessment results must be available in at least a daily note or a weekly summary. Data must be collected as described in the ISP, analyzed, summarized, and then clearly addressed in the CSP.

3. In addition to licensing requirements, persons providing residential support services are required to participate in training specified by DMAS in the characteristics of SED. The training shall include appropriate interventions, training strategies, and support methods for individuals with SED.

4. The ISP must be reviewed by the provider with the client or family/caregiver, as appropriate, and this review submitted to the case manager, at least semi-annually, with goals, objectives, and activities modified as appropriate.

5. Documentation must be maintained for supervision and oversight of all in-home residential support staff. All significant contacts must be documented.

6. Required documentation in the client’s record. The provider agency must maintain records of each client receiving residential support services. Documentation must be completed and signed by the staff person designated to perform the supervision and oversight. At a minimum, these records must contain the following:

a. Date of contact or observation and the amount of time spent;

b. Person or persons contacted or observed;

c. A note regarding staff performance and ISP service delivery for monthly contact and semi-annual home visits;

d. Semi-annual observation documentation must also address client’s and family/caregiver’s satisfaction with service provision;

e. Any action planned or taken to correct problems identified during supervision and oversight;

f. A functional assessment conducted by the provider to evaluate each client in the residential environment and community settings; and

g. An ISP that must contain the following elements:

(1) The client’s strengths, desired outcomes, required or desired supports, or both, and training needs;

(2) The client’s or family/caregiver’s goals and measurable objectives to meet the identified outcomes;

(3) The services to be rendered and the schedule of services to accomplish the goals, objectives, and desired outcomes;

(4) A timetable for the accomplishment of the client’s goals and objectives;

(5) The estimated duration of the client’s needs for services; and

(6) The provider staff responsible for the overall coordination and integration of the services specified in the ISP.

h. The ISP goals, objectives, and activities must be reviewed by the provider quarterly, annually, and more often as needed, modified as appropriate, and results of these reviews submitted to the case manager. For the annual review and in cases where the ISP is modified, the ISP must be reviewed with and approved by the client and family/caregiver.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. December 1, 2007.

12VAC30-135-310. (Reserved.)

12VAC30-135-320. Therapeutic consultation.

A. Service description.

1. Therapeutic consultation is available through the CMH Waiver for Virginia-licensed or certified practitioners in psychology, social work, occupational therapy, therapeutic recreation, rehabilitation, speech/language therapy, professional counseling, marriage and family therapy, medicine, psychiatric clinical nurse specialists, and psychiatric nurse practitioners. Behavioral consultation performed by these individuals may also be a covered waiver service. These services may be provided, based on the client’s ISP, for those clients for whom specialized consultation is clinically necessary to enable their utilization of waiver services.

2. Therapeutic consultation provides expertise, training and technical assistance for any of the specialty providers listed above to assist family members, caregivers, and other service providers in supporting the client. The specialty areas are (i) psychology, (ii) behavioral consultation, (iii) therapeutic recreation, (iv) speech and language pathology, and (v) occupational therapy. The need for any of these services is based on the client’s ISP and provided to those clients for whom specialized consultation is clinically necessary and who have additional challenges restricting their ability to function in the community. Therapeutic consultation services may be provided in the client’s home, and in appropriate community settings and are intended to facilitate implementation of the individual’s and family/caregiver’s desired outcomes as identified in his ISP.

3. Therapeutic consultation services may be provided in in-home residential or treatment support settings or in office settings in conjunction with another service. Behavioral consultation may be offered in the absence of any other waiver service when the consultation provided to informal caregivers is determined to be necessary to prevent institutionalization. Therapeutic consultation service providers are reimbursed according to the amount and type of service authorized in the ISP based on an hourly fee-for-service rate.

B. Criteria. In order to qualify for these services, the client shall have a demonstrated need for consultation in any of these services. Documented need must indicate that the ISP cannot be implemented effectively and efficiently without such consultation from this service.

1. The client’s therapeutic consultation supporting documentation must clearly reflect the client’s needs, as documented in the assessment, for specialized consultation provided to family/caregivers and providers in order to implement the ISP effectively.

2. Therapeutic consultation services may not include direct therapy provided to waiver clients or monitoring activities, and may not duplicate the activities of other services that are available to the client through the State Plan for Medical Assistance.

C. Service units and service limitations. The unit of service shall equal one hour. The services must be explicitly detailed in the ISP or supporting documentation. Travel time, written preparation, and telephone communication are not billable as separate items. Therapeutic consultation may not be billed solely for purposes of monitoring.

D. Provider requirements. In addition to meeting the general conditions and requirements for home and community-based participating providers as specified in 12VAC30-135-120 and 12VAC30-135-160, professionals rendering therapeutic consultation services, including behavioral consultation services, shall meet all applicable state or national licensure, endorsement or certification requirements. Behavioral consultation may be performed by professionals based on the professionals’ work experience, education, and demonstrated knowledge, skills, and abilities.

The following documentation is required for therapeutic consultation:

1. ISP, that contains at a minimum, the following elements:

a. Identifying information: client’s name and Medicaid number; provider name and provider number; responsible person and telephone number; effective dates for supporting documentation; and semi-annual review dates, if applicable;

b. Targeted objectives, time frames, and expected outcomes;

c. Specific consultation activities; and

d. The expected outcomes.

2. A written support plan detailing the recommended interventions or support strategies for providers and family/caregivers to use to better support the client in the service.

3. Ongoing documentation of consultative services rendered in the form of contact-by-contact or monthly notes that identify each contact. All monthly, quarterly, semi-annual and annual notes must include:

a. Specific details of the activities conducted;

b. Dates, locations, and times of service delivery;

c. Supporting documentation objectives addressed;

d. Services delivered as planned or modified;

e. Effectiveness of the strategies and client’s and family/caregiver’s satisfaction with service;

f. Client status; and

g. Consultation outcomes and effectiveness of support plan.

4. If consultation services extend less than three months, the provider must forward monthly contact notes or a summary of them to the case manager.

5. If the consultation services extend three months or longer, written quarterly reviews must be completed by the service provider and are to be forwarded to the case manager. Any changes to the ISP must be reviewed with the client and family/caregiver.

6. Semi-annual reviews are required by the service provider if consultation extends three months or longer and are to be forwarded to the case manager.

7. If the consultation service extends beyond one year, the ISP must be reviewed by the provider with the client and family/caregiver and the case manager. The written review must be submitted to the case manager, at least annually, or more often as needed.

8. A written support plan, detailing the interventions and strategies for staff, family, or caregivers to use to better support the client in the service.

9. A final disposition summary must be forwarded to the case manager within 30 days following the end of this service and must include:

a. Strategies utilized;

b. Objectives met;

c. Unresolved issues; and

d. Consultant recommendations.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. December 1, 2007.

12VAC30-135-330. (Reserved.)

12VAC30-135-340. Reevaluation of service need and quality management review.

A. The comprehensive service plan (CSP).

1. The CSP shall be developed by the case manager in coordination with others involved in the care of the client based on relevant, current assessment data. The CSP process determines the services to be rendered to clients, the frequency of services, the type of service provider, and a description of the services to be offered. All CSPs developed by the case manager are subject to approval by DMAS.

2. The case manager shall be responsible for continuous monitoring of the appropriateness of the client’s CSP and revisions to the CSP as indicated by the changing needs of the client. At a minimum, the case manager must review the CSP every three months to determine whether service goals and objectives are being met and whether any modifications to the CSP are necessary.

3. The DMAS staff will review the CSP every 12 months or more frequently as required to assure proper utilization of services. Any modification to the amount or type of services in the CSP must be authorized by DMAS.

B. Review of level-of-care.

1. The case manager must complete an annual comprehensive reassessment, in coordination with the individual, family/caregivers and service providers. If warranted, the case manager will coordinate a medical examination and a mental health evaluation for each waiver client. The reassessment must include an update of the assessment instrument and any other appropriate assessment data.

2. Medical examinations must be completed according to the recommended frequency and periodicity of the EPSDT program.

3. The mental health assessment for clients must reflect the current psychological status (diagnosis) and adaptive level of functioning. A new mental health assessment shall be required whenever the current mental health assessment is no longer reflective of the child’s current condition.

C. Documentation required.

The case management agency must maintain the following documentation for review by the DMAS staff for each waiver client:

1. All CSPs, assessment summaries, and supporting documentation completed for the client and retained for a period of not less than six years from each client’s last date of service or as provided by applicable state or federal laws; whichever period is longer. Records of minors shall be kept for at least six years after such minor has reached the age of 18 years;

2. All individual providers’ ISPs from any provider rendering waiver services to the client and all supporting documentation related to any change in the ISPs;

3. All supporting documentation related to any change in the CSP;

4. All related communication with the providers, client, consultants, DMHMRSAS, CSA, DMAS, DSS, DRS; and others involved in the care of the child; and

5. An ongoing log that documents all contacts made by the case manager related to the waiver client.

6. All supporting documentation developed for the client and retained for a period of not less than six years from each client’s last date of service or as provided by applicable state or federal laws, whichever period is longer. Records of minors shall be kept for at least six years after such minor has reached the age of 18 years;

7. An attendance log that documents the date services were rendered and the amount and type of services rendered; and

8. Appropriate progress notes reflecting client’s status and, as appropriate, progress toward the goals on the CSP.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. December 1, 2007.

12VAC30-135-350. (Reserved.)

12VAC30-135-360. Sunset provision.

Consistent with federal requirements applicable to this §1915(c) demonstration waiver, these regulations shall expire effective with the termination of the federally approved waiver.

Statutory Authority

§§32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. December 1, 2007.

DOCUMENTS INCORPORATED BY REFERENCE

Child Adolescent Functional Assessment Scale (Uniform Assessment Instrument), Functional Assessment Systems, 2000.