Virginia Regulatory Town Hall

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VIDES Criteria for care in Intermediate Care Facilities for ...
Stage: Fast-Track
 
12VAC30-60-360

12VAC30-60-360. Criteria for care in facilities for mentally retarded persons. (Repealed.)

§ 4.0 Definitions. The following words and terms, when used in these criteria, shall have the following meaning, unless the context clearly indicated otherwise:

"no assistance" shall mean no help is needed.

"prompting/structuring" shall mean prior to the functioning, some verbal direction and/or some rearrangement of the environment is needed.

"supervision" shall mean that a helper must be present during the function and provide only verbal direction, general prompts, and/or guidance.

"some direct assistance" shall mean that helper must be present and provide some physical guidance/support (with or without verbal direction).

"total care" shall mean that a helper must perform all or nearly all of the functions.

"rarely" shall mean that a behavior occurs quarterly or less.

"sometimes" shall mean that a behavior occurs once a month or less.

"often" shall mean that a behavior occurs 2-3 times a month.

"regularly" shall mean that a behavior occurs weekly or more.

§ 4.1 Utilization Control regulations require that criteria be formulated for guidance for appropriate levels of services. Traditionally, care for the mentally retarded has been institutionally based; however, this level of care need not be confined to a specific setting. The habilitative and health needs of the client are the determining issues.

§ 4.2 The purpose of these regulations is to establish standard criteria to measure eligibility for Medicaid payment. Medicaid can pay for care only when the client is receiving appropriate services and when "active treatment" is being provided. An individual's need for care must meet these criteria before any authorization for payment by Medicaid will be made for either institutional or waivered rehabilitative services for the mentally retarded.

§ 4.3 Care in facilities for the mentally retarded requires planned programs for habilitative needs and/or health related services which exceed the level of room, board, and supervision of daily activities.

Such cases shall be combination of habilitative, rehabilitative, and health services directed toward increasing the functional capacity of the retarded person. Examples of services shall include training in the activities of daily living, task-learning skills, socially acceptable behaviors, basic community living programming, or health care and health maintenance. The overall objective of programming shall be the attainment of the optimal physical, intellectual, social, or task learning level which the person can presently or potentially achieve.

§ 4.4 The evaluation and re-evaluation for care in a facility for the mentally retarded shall be based on the needs of the person, the reasonable expectations of the resident's capabilities, the appropriateness of programming, whether progress is demonstrated from the training and, in an institution, whether the services could reasonably be provided in a less restrictive environment.

§ 4.5 Patient assessment criteria. The patient assessment criteria are divided into broad categories of needs, or services provided. These must be evaluated in detail to determine the abilities/skills which will be the basis for the development of a plan for care. The evaluation process will demonstrate a need for programming an array of skills and abilities or health care services. These have been organized in seven major categories. Level of functioning in each category is graded from the most dependent to the least dependent. In some categories, the dependency status is rated by the degree of assistance required. In other categories, the dependency is established by the frequency of a behavior or ability to perform a given task.

§ 4.6 The resident must meet the indicated dependency level in TWO OR MORE of categories 1 through 7.

1. Two or more questions must be answered with a 4, OR

2. Question "j" must be answered "yes."

B. Communication Skills - To meet this category three or more questions must be answered with a 3 or a 4.

C. Task Learning Skills - To meet this category three or more questions must be answered with a 3 or a 4.

D. Personal Care - To meet this category

1. Question "a" must be answered with a 4 or a 5, OR

2. Question "b" must be answered with a 4 or a 5, OR

3. Questions "c" and "d" must be answered with a 4 or a 5.

E. Mobility - To meet this category any one question must be answered with a 4 or a 5.

F. Behavior - To meet this category any one question must be answered with a 3 or a 4.

G. Community Living - To meet this category

1. Any two of the questions "b", "e", or "g" must be answered with a 4 or a 5, OR

2. Three or more questions must be answered with a 4 or a 5.

§ 4.7. Level of functioning survey.

 

A. HEALTH STATUS

 

How often is nursing care or nursing supervision by a licensed nurse required for the following? (Key:1=rarely, 2=sometimes, 3=often, and 4=regularly)

 

1. Medication administration and/or evaluation for effectiveness of a medication regimen?

1

2

3

4

 

2. Direct services: i.e., care for lesions, dressings, treatments, (other than shampoos, foot power, etc.)

1

2

3

4

 

3. Seizures control

1

2

3

4

 

4. Teaching diagnosed disease control and care, including diabetes

1

2

3

4

 

5. Management of care of diagnosed circulatory or respiratory problems

1

2

3

4

 

6. Motor disabilities which interfere with all activities of Daily Living - Bathing, Dressing, Mobility, Toileting, etc.

1

2

3

4

 

7. Observation for choking/aspiration while eating, drinking?

1

2

3

4

 

8. Supervision of use of adaptive equipment, i.e., special spoon, braces, etc.

1

2

3

4

 

9. Observation for nutritional problems (i.e., undernourishment, swallowing difficulties, obesity)

1

2

3

4

 

10. Is age 55 or older, has a diagnosis of a chronic disease and has been in an institution 20 years or more

1

2

3

4

 

B. COMMUNICATION

 

Using the Key 1=regularly, 2=often, 3=sometimes, 4=rarely, how often does this person

 

1. Indicate wants by pointing, vocal noises, or signs?

1

2

3

4

 

2. Use simple words, phrases, short sentences?

1

2

3

4

 

3. Ask for at least ten things using appropriate names?

1

2

3

4

 

4. Understand simple words, phrases or instructions containing prepositions: i.e., on in behind?

1

2

3

4

 

5. Speak in an easily understood manner?

1

2

3

4

 

6. Identify self, place of residence, and significant others?

1

2

3

4

 

C. TASK LEARNING SKILLS

 

How often does this person perform the following activities (Key: 1=regularly, 2=often, 3=sometimes, 4=rarely)

 

1. Pay attention to purposeful activities for 5 minutes?

1

2

3

4

 

2. Stay with a 3 step task for more than 15 minutes?

1

2

3

4

 

3. Tell time to the hour and understand time intervals?

1

2

3

4

 

4. Count more than 10 objects?

1

2

3

4

 

5. Do simple addition, subtraction?

1

2

3

4

 

6. Write or print ten words?

1

2

3

4

 

7. Discriminate shapes, sizes, or colors?

1

2

3

4

 

8. Name people or objects when describing pictures?

1

2

3

4

 

9. Discriminate between one, many, lot?

1

2

3

4

 

D. PERSONAL and SELF CARE

 

With what type of assistance can this person currently (Key: 1=No Assistance, 2=Prompting/Structures, 3=Supervision, 4=Some Direct Assistance, 5=Total Care)

 

1. Perform toileting functions: i.e., maintain bladder and bowel continence, clean self, etc.?

1

2

3

4

5

 

2. Perform eating/feeding functions: i.e., drinks liquids and eats with spoon or fork, etc.?

1

2

3

4

5

 

3. Perform bathing function: i.e., bathes, runs bath, dry self, etc.?

1

2

3

4

5

 

4. Dress self completely, i.e., including fastening, putting on clothes, etc.?

1

2

3

4

5

 

E. MOBILITY

 

With what type of assistance can this person currently (Key: 1=No Assistance, 2=Prompting/Structures, 3=Supervision, 4=Some Direct Assistance, 5=Total Care)

 

1. Move, (walking, wheeling) around environment?

1

2

3

4

5

 

2. Rise from lying down to sitting positons, sits without support?

1

2

3

4

5

 

3. Turn and position in bed, roll over?

1

2

3

4

5

 

F. BEHAVIOR

 

How often does this person (Key:1=Rarely, 2=Sometimes, 3=Often, and 4=Regularly)

 

1. Engage in self destructive behavior?

1

2

3

4

 

2. Threaten or do physical violence to others?

1

2

3

4

 

3. Throw things, damage property, have temper outbursts?

1

2

3

4

 

4. Respond to others in a socially unacceptable manner - (without undue anger, frustration, or hostility)

1

2

3

4

 

G. COMMUNITY LIVING SKILLS

 

With what type of assistance can this person currently (Key:1=No Assistance, 2=Prompting/Structures, 3=Supervision, 4=Some Direct Assistance, 5=Total Care)

 

1. Prepare simple foods requiring no mixing or cooking?

1

2

3

4

5

 

2. Take care of personal belongings, room (excluding vacuuming, ironing, clothes washing/drying, wet mopping)?

1

2

3

4

5

 

3. Add coins of various denominations up to one dollar?

1

2

3

4

5

 

4. Use the telephone to call home, doctor, fire, police?

1

2

3

4

5

 

5. Recognize survival signs/words: i.e., stop, go, traffic lights, police, men, women, restrooms, danger, etc.?

1

2

3

4

5

 

6. Refrain from exhibiting unacceptable sexual behavior in public?

1

2

3

4

5

 

7. Go around cottage, ward, building, without running away, wandering off, or becoming lost?

1

2

3

4

5

 

8. Make minor purchases, i.e., candy, soft drink, etc?

1

2

3

4

5
12VAC30-60-361

THE TEXT OF THIS REGULATION IS IN DRAFT FORM AND SHOULD NOT BE RELIED UPON FOR LEGAL INTERPRETATION.

12VAC30-60-361. VIDES criteria for care in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID).

A. This section establishes standard criteria that shall be met by individuals in order to receive Medicaid payment for care in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID).  Once the individual has been screened and found to meet these critieria, Medicaid covers care only when the individual is receiving appropriate services and when active treatment, as defined in 42 CFR 483.440(a), is being provided.  An individual's need for care shall meet the level of functioning criteria in the Virginia Individual Developmental Disability Eligibility Survey (VIDES) form before any authorization for payment by Medicaid will be made for institutional services.

B. Care which is provided in facilities for individuals with developmental or intellectual disabilities, for the purpose of claiming Medicaid reimbursement, requires planned programs of services to address habilitative needs or health needs, or both, that exceed the level of room and board and general supervision of daily activities.

1. Such care may be a combination of habilitative, rehabilitative, and health services directed towards increasing or maintaining the skills and abilities capacity of the individual. Examples of such care include: (i) skill building in the Activities of Daily Living (ADLs); (ii) skill building in task-learning skills; (iii) learning socially acceptable behaviors; (iv) basic community living supports and skill building; (v) health care and health maintenance, and; (vi) skill building in self direction.

2. The overall objective of facility based supports shall be the attainment of the optimal physical, intellectual, social, or task learning level that the individual can presently or potentially achieve.

C. Screening process for entrance into an ICF/IID shall be coordinated through DMAS or its designee.

1. DMAS or its designee shall accept requests for ICF/IID screenings and ensure that, within seven calendar days of referral, those screenings are scheduled.

2. DMAS or its designee shall assign the screening to the CSB/BHA that serves the area of the individual's residence. In instances when the CSB/BHA owns or operates the ICF/IID, an alternative approved screener may be assigned.

3. DMAS or its designee shall also explore and review more integrated options with the individual and family/guardian at the time of screening and through the established review recommendations and procedures with DBHDS.  DOES THIS MEAN SUPPORT IN THE COMMUNITY??

D. The evaluation and re-evaluation for determination of the ICF/IID level of care shall be based on (i) the needs of the individual; (ii) the reasonable expectations of the individual's capabilities; (iii) the appropriateness of services to be provided; (iv) the progress the individual demonstrates from the skill building; and (v) in an institution, whether the services could reasonably be provided in a less restrictive environment.  COMMUNITY??  THIS ITEM (v) DOES NOT MAKE SENSE HERE.  THIS WHOLE SECTION IS FOR INSTITUTIONAL PLACEMENT --- WHY DOES A LESS RESTRICTIVE ENVIRONMENT EVEN COME UP ????

E. Individual assessment criteria. The individual assessment criteria shall be evaluated BY WHOM?? in detail to determine the skills, abilities, and status that will be the basis for the development of an Individual Support Plan (ISP). The evaluation process shall indicate a need for an ISP that addresses the individual's skills, abilities, and need for health care services which have been organized in the eight major categories set forth in subsection F of this section. Level of functioning dependency in each category is indicated from the most dependent to the least dependent. In some categories, the dependency status is rated by the degree of assistance required. In other categories, the dependency is established by the frequency of a behavior or the ability to perform a given task.

F. Dependency level. The adult-individual (18 years of age and older) shall demonstrate an overall total level for the VIDES assessment of dependency in three or more of the skills or statuses listed in subdivisions 1 through 8 of this subsection. To demonstrate a skill or exhibit a status, the individual shall meet the criteria for the dependency level described for that skill or status. The questions referenced in subdivisions 1 through 8 of this subsection to meet the criteria of a dependency level are found in Table 1 of this subsection.  Children (ages three years through 17 years old) and infants (younger than three years of age) shall demonstrate an overall total level for the VIDES assessment of dependency in two or more areas for the VIDES specific for the child's or infant's age.

1. Health status.  To meet the criteria for this category:

a. Any two or more questions shall be answered with a score of 4 for the Adult VIDES;

b. Any one question shall be answered with a score of 4 for the Child VIDES (ages 3-5 years old);

c. Any two or more questions shall be answered with a score of 4 for the Child VIDES (ages 6 through 17 years); or

d. Any one question shall be answered with a score of 3 or 4 for the Infant VIDES.

2. Communication skills.

a. Any three or more questions shall be answered with a score of 3 or 4 for the Adult VIDES;

b. Any three or more questions shall be answered with a score of 3 or 4 for the Child VIDES (ages 3 or older);

c. Any two or more questions shall be answered with a score of 3 or 4 for the Infant VIDES (ages 6 months or 2 years of age); or

d. Any one or more questions shall be answered with a score of 3 or 4 for the Infant VIDES (ages one year or 18 months).

3. Task learning skills.

a. Any three or more questions shall be answered with a score of 3 or 4 for the Adult VIDES;

b. Any one question shall be answered with a score of 3 or 4 for the Child VIDES (ages 3-5 years old);

c. Any two questions shall be answered with a score of 3 or 4 for the Child VIDES (ages 6-9 years old);

c. Any three or more questions shall be answered with a score of 3 or 4 for the Child VIDES (ages 10 through 17 years);

d. Any one question shall be answered with a score of 3 or 4 for the Infant VIDES (age 6 months); or

e. Any two or more questions shall be answered with a score of 3 or 4 for the Infant VIDES (ages 12 months and 18 months).   

4. Personal/self-care skills.

a. Any one question shall be answered with a 4 or 5 for the Adult VIDES; or

b. Any one question shall be answered with a 4 or 5 for the Child VIDES (ages 3 years through 17 years).

5. Motor skills.

a. Any two or more??? questions shall be answered with a 4 or 5 for the Adult VIDES;

b. Any two or more questions shall be answered with a 4 or 5 for the Child VIDES (ages 3 through 17 years);

c. Any two or more questions shall be answered with a 3 or 4 for the Infant VIDES (ages 6 months or 2 years); or

d. Any one or more questions shall be answered with a 3 or 4 for the Infant VIDES (ages 12 months or 18 months).

SO WE ARE EXPECTING A BABY (6 MONTHS OLD) TO MEET TWICE THE STANDARD THAT A 12 MONTHS OLD MEETS?  BY VIRTUE OF AGE, A 6 MONTH OLD SHOULD NOT BE EXPECTED TO HAVE THE MOTOR SKILLS OF A 12 MONTHS OLD BABY----I'M CONFUSED.

6. Behavior status.

a. Any one question shall be answered with a 3 or 4 for the Adult VIDES;

b. Any one question shall be answered with a 4 or 5 for the Child VIDES (ages 3 through 17 years);

c. Any two or more questions shall be answered with a 3 or 4 (in the Social/emotional category) for the Infant VIDES (ages 6 months or 2 years); or

d. Any one or more questions shall be answered with a 3 or 4 for the Infant VIDES (ages 12 months or 18 months).

7. Community living skills.

a. Three or more questions shall be answered with a 4 or 5 for the Adult VIDES;

b. Any two or more??? questions shall be answered with a 4 or 5 for Child VIDES (ages 6 years through 7 years); or

c. Any three or more questions shall be answered with 4 or 5 for the Child VIDES (ages 8 years through 17 years).

8. Self-direction skills.

a. Any three or more questions shall be answered with a 2 for the Adult VIDES;

b. Any one question shall be answered with a 2 for the Child VIDES (ages 10 years and 11 years); or

c. Any two or more questions shall be answered with a 2 for the Child VIDES (ages 12 years through 17 years).

G. Upon admisison to an ICF/IID, the faciltiy shall perform an assessment of the individual consistent with 42 CFR 443.20.