The following words or terms when used in this regulation shall have the following meanings unless the content clearly indicates otherwise.
"Activities of daily living" or "ADLs" means bathing, dressing, toileting, transferring, and eating/feeding. An individual's degree of independence in performing these activities is a part of determining [ the ] appropriate level of care and service needs.
"Administrator" means the person who oversees the day-to-day operation of the facility, including compliance with all regulations for licensed assisted living facilities.
"Admissions summary" means the Virginia Uniform
Assessment Instrument and other relevant social, psychological, and medical
information gathered by the assisted living facility staff for use in the
development and updates of the [
plan of care
individual service plan ].
"Alzheimer's" means a diagnosis of Alzheimer's as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV-TR), published by the American Psychiatric Association.
and Related Dementias Assisted Living
Waiver" or "AAL Waiver" means the CMS-approved waiver that
covers a range of community support services offered to individuals who have a
diagnosis of Alzheimer's or a related dementia who meet nursing facility level
"Americans with Disabilities Act" or "ADA" means the United States Code pursuant to 42 USC § 12101 et seq., as amended.
"Appeal" means the process used to challenge
actions regarding services, benefits, and reimbursement provided by Medicaid
pursuant to 12VAC30-110 and 12VAC30-20-500 through 12VAC30-20-560.
"Assisted living facility" means a congregate residential setting as defined in § 63.2-100 of the Code of Virginia.
"Auxiliary Grant Program" means a state and locally
funded assistance program to supplement the income of [
individual who receives ] Supplemental Security Income (SSI) [ recipient ]
or an adult who would be eligible for SSI except for excess income and who
[ resides lives ] in a licensed assisted living
facility with an approved rate.
"Barrier crime" means those crimes as defined in § 32.1-162.9:1 of the Code of Virginia.
"Comprehensive assessment" means the Virginia
Uniform Assessment Instrument and other relevant social, psychological and
medical information gathered by the assisted living facility staff for use in
the development and updates of the plan of care.
"CMS" means the Centers for Medicare and Medicaid Services, which is the unit of the U.S. Department of Health and Human Services that administers the Medicare and Medicaid programs.
[ "Designated preauthorization or service contractor" means DMAS or the entity that has been contracted by DMAS to perform preauthorization of services or service authorizations. ]
"Direct marketing" means either (i) conducting directly or indirectly door-to-door, telephonic or other "cold call" marketing of services at residences and provider sites; (ii) mailing directly; (iii) paying "finders' fees"; (iv) offering financial incentives, rewards, gifts or special opportunities to eligible individuals or family/caregivers as inducements to use the providers' services; (v) continuous, periodic marketing activities to the same prospective individual or family/caregiver for example, monthly, quarterly, or annual giveaways as inducements to use the providers' services; or (vi) engaging in marketing activities that offer potential customers rebates or discounts in conjunction with the use of the providers' services or other benefits as a means of influencing the individual's or family/caregiver's use of the providers' services.
"DMAS" means the Department of Medical Assistance Services.
"DMAS staff" means persons employed by the Department of Medical Assistance Services.
"DSS" means the Virginia Department of Social Services.
"Enrolled provider" means an entity that is either licensed or certified by the appropriate state agency that also meets the standards and requirements set forth by DMAS and has a current, signed provider participation agreement with DMAS.
"Designated preauthorization contractor"
means DMAS or the entity that has been contracted by DMAS to perform
preauthorization of services. ]
"Home and community-based waiver services" or
"waiver services" means the range of community support services
approved by the CMS pursuant to § 1915(c) of the Social Security Act to be
offered to persons who are elderly or disabled who would otherwise require the
level of care provided in a nursing facility. DMAS or the designated [
preauthorization/service authorizations ] contractor shall only
give [ preauthorization preauthorization/service authorization ]
for medically necessary Medicaid-reimbursed home and community care.
"Individual" means the person receiving the services established in these regulations and who (i) meets the eligibility criteria for residing in a safe, secure environment as described in 22VAC40-72-10; (ii) meets the eligibility criteria for the AAL Waiver; and (iii) resides in a safe, secure environment of an assisted living facility.
[ "Individual service plan" means the written individual plan developed by the provider related solely to the specific services required by the individual to ensure optimal health and safety while living in the assisted living facility.
"Legally authorized representative" means a person legally responsible for representing or standing in the place of an individual for the conduct of the individual's affairs. This may include a guardian, conservator, attorney-in-fact under durable power of attorney, trustee, or other person expressly named by a court of competent jurisdiction or the individual as his agent in a legal document that specifies the scope of the representative's authority to act. A legally authorized representative may only represent or stand in the place of the individual for the function or functions for which he has legal authority to act. ]
"Licensed health care professional" or "LHCP" means any health care professional currently licensed by the relevant health regulatory board of the Department of Health Professions of the Commonwealth who is practicing within the scope of his license.
"Participating provider" means an entity that
meets the standards and requirements set forth by DMAS, and has a current,
signed provider participation agreement with DMAS.
"Plan of care" means the written plan
developed by the provider related solely to the specific services required by
the individual to ensure optimal health and safety while remaining in the
assisted living facility. ]
"Preadmission screening" means the process to: (i) evaluate the functional, nursing, and social supports of individuals referred for preadmission screening; (ii) assist individuals in determining what specific services the individuals need; (iii) evaluate whether a service or a combination of existing community services are available to meet the individuals' needs; and (iv) refer individuals to the appropriate provider for Medicaid-funded nursing facility or home and community-based care for those individuals who meet nursing facility level of care.
"Preadmission screening team" means the entity contracted with DMAS that is responsible for performing preadmission screening pursuant to § 32.1-330 of the Code of Virginia.
"Related dementia" means a diagnosis of Dementia of the Alzheimer's Type as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV-TR), published by the American Psychiatric Association.
"Resident" means any individual who (i) meets the
eligibility criteria for residing in a safe, secure environment as described in
22VAC40-71-700 C 1; (ii) meets eligibility criteria for the AAL Waiver; and
(iii) resides in a safe, secure environment of an assisted living facility.
"Safe, secure environment" means a self-contained
special care unit as defined in
"State Plan for Medical Assistance" or
"Plan" means the [
regulations Commonwealth's legal
document approved by the Centers for Medicare and Medicaid Services ]
identifying the covered groups, covered services and their limitations, and
provider reimbursement methodologies as provided for under Title XIX of the
Social Security Act.
"Virginia Uniform Assessment Instrument" or
"UAI" means the standardized multidimensional questionnaire that is
completed by the preadmission screening team, [ in a face-to-face
meeting with the individual and legally authorized representative, as may be
appropriate, ] which assesses an individual's physical health, mental
health, [ and ] social [
, ] and functional
abilities to determine if the individual meets the level of care for certain
publicly funded long-term care programs such as nursing facility services.
12VAC30-120-1605. Waiver description and legal authority.
This Alzheimer's waiver operates under the authority of
§ 1915 (c) of the Social Security Act and 42 CFR 430.25(c)(2), which
permit the waiver of certain State Plan requirements. These federal statutory
and regulatory provisions permit the establishment of Medicaid waivers to
afford the states with greater flexibility to devise different approaches to
the provision of long-term care services. This particular waiver provides [
recipients eligible individuals ] who have a diagnosis
of Alzheimer's or related dementias with supportive services to enable such individuals
to remain in their communities.
12VAC30-120-1610. Individual eligibility requirements.
A. Waiver service population. The AAL Waiver shall be
available through a § 1915(c) of the Social Security Act waiver to eligible
aged and disabled [
auxiliary grant recipients Auxiliary Grant
individuals ] who [ reside live ] in
licensed assisted living facilities.
B. Eligibility criteria. To qualify for AAL Waiver services, individuals must meet all of the following criteria:
1. The waiver individual must be either:
a. Elderly as defined by § 1614 of the Social Security Act; or
b. Disabled as defined by § 1614 of the Social Security Act.
2. The waiver individual must meet the criteria for admission to a nursing facility as determined by a preadmission screening team using the full UAI.
3. The waiver individual must have a diagnosis of
Alzheimer's or a related dementia as diagnosed by a licensed clinical
psychologist or a licensed physician. The individual may not have a diagnosis
of mental [
retardation retardation/intellectual disability ]
as defined by the American Association on Mental Retardation in Mental
Retardation Intellectual and Developmental Disabilities [ ,
User's Guide Mental Retardation: Definition, Classifications Classification
and Systems of Supports, 10th Edition ], or a serious mental illness
as defined in 42 CFR 483.102(b).
4. The waiver individual must be receiving an [
grant Auxiliary Grant ], and [ residing living ]
in or seeking admission to a safe, secure unit of a DMAS-approved DMAS-enrolled
assisted living facility.
C. Assessment. Medicaid will not pay for any AAL Waiver
services delivered prior to the date of the preadmission screening by the
preadmission screening team and the physician signature on the Medicaid-Funded
Long-Term Care Services Authorization Form (DMAS-96). Medicaid will not pay for
any AAL Waiver services delivered prior to the individual's
effective date of Medicaid eligibility [ and qualification
for an Auxiliary Grant ].
After an initial 60-day application period
and a random selection process to determine the order in which eligible individuals
will be served by this waiver For the enrollment of all CMS-approved
waiver slots, individuals will be served [ handled
reviewed ] on a first-come, first-served basis in accordance with
available waiver funding. If there is not a waiver slot available for an
individual, the individual shall be placed on the waiting list. Individuals
must meet all waiver eligibility criteria in order to be placed on the waiting
list. [ Individuals must meet all waiver eligibility criteria in
order to be placed on the waiting list. ]
E. Preauthorization. Before a provider can bill DMAS for AAL Waiver services, preauthorization must be obtained from DMAS. Providers must submit all required information to the designated preauthorization contractor within 10 business days of initiating care. If the provider submits all required information to the designated preauthorization contractor within 10 business days of initiating care, services may be authorized beginning from the date the provider initiated services but not preceding the date of the physician's signature on the Medicaid-Funded Long-Term Care Services Authorization Form (DMAS-96). If the provider does not submit all required information to either the designated preauthorization contractor or DMAS within 10 business days of initiating care, the services may be authorized beginning with the date all required information was received by the designated preauthorization contractor, but in no event preceding the date of the preadmission screening team physician's signature on the DMAS-96.
F. Review of the waiver individual's level of care. DMAS conducts this review based on the documentation submitted by the provider. The level of care assessments are performed to ensure that individuals receiving services in the waiver continue to meet the criteria for the waiver.
G. Termination of services. In the case of termination of AAL
Waiver services by DMAS, waiver individuals shall be notified of their
appeal rights pursuant to 12VAC30-110, Eligibility and Appeals. DMAS may terminate
AAL Waiver [
care ] services for any of the following reasons:
1. The AAL Waiver is no longer required to prevent or delay institutional placement;
2. The waiver individual is no longer eligible for Medicaid;
3. The waiver individual is no longer eligible to receive an auxiliary grant;
4. The waiver individual no longer meets AAL Waiver criteria;
5. The waiver individual has been absent from, or has not received services from, the assisted living facility for more than 30 consecutive days;
6. The waiver individual's environment does not provide for his health, safety, and welfare; or
7. The assisted living facility no longer meets safe and secure
licensing standards set by
VDSS DSS or standards set by DMAS for
12VAC30-120-1620. Covered services.
A. Assisted living services include personal care
services, homemaker, chore, attendant care, and companion services. This service
includes 24-hour on-site response staff to meet scheduled or unpredictable
needs in a way that promotes maximum dignity and independence, and to provide
supervision, safety and security.
B. For purposes of these regulations, assisted living services shall also include:
1. Medication administration. Medications shall be administered
an individual a [ provider
provider's ] employee who is currently licensed [ or
registered ] to administer medications [ (physician, (for
example: physician, ] physician assistant, pharmacist, nurse
practitioner, [ RN, ] or LPN), [ LPN, ] licensed
health care professional (LHCP), or registered medication [ aide
aide) ], except on the 11 p.m. to 7 a.m. shift when medications may
be administered by a medication aide that [ who ] meets
[ by meeting ] the regulatory requirements as set forth by the
Department of Social Services DSS and the Board of Nursing appropriate
licensing board of the Department of Health Professions in the Commonwealth;
Nursing evaluations. Individual summaries. The
RN LHCP must complete a comprehensive assessment an
admissions summary of each resident individual upon admission
to the facility and when a significant change in health status or
behavior occurs in one of the following areas: weight loss, elopements,
behavioral symptoms, or adverse reactions to prescribed medication. A RN
LHCP shall identify resident individual care problem areas
and formulate interventions [ , to the extent permitted by his license, ]
to address those problems and to evaluate [ , to the extent permitted
by his license, ] if the planned interventions were successful;
3. [ Skilled nursing services.
LHCP services ]
Skilled nursing [ LHCP ] services are nursing services
that are used to complete resident assessments individual summaries
and administer medications, and provide training, consultation, and oversight
of direct care staff. Skilled nursing [ LHCP ] services
must be provided by a RN or by a LPN under the supervision of a RN LHCP
who is licensed to practice in the state and provided in accordance and within
the scope of practice specified by state law; and
4. Therapeutic social and recreational programming. An activity
program must be designed to meet the
individual specific needs of
each resident waiver individual and to provide daily activities
appropriate to [ residents individuals ] with Alzheimer's
or related dementia.
a. This program shall be individualized and properly implemented, followed, and reviewed as changes are needed.
Residents Waiver individuals who have
wandering behaviors shall have an activity program to address these behaviors.
There Consistent with 22VAC40-72-1100,
there ] shall be [ a minimum of ] 19 [ 16
hours of planned ] group [ programming structured
group activities ] each week, not to include activities of daily
living. d. Each resident must receive [ As part of these 16
hours, there There ] shall be at least one hour of
one-on-one activity per week, not to include activities of daily living. This
activity must be provided exclusively by activities staff. Such
one-on-one activities may be rendered by such licensed or volunteer staff as
determined appropriate by the provider. e. d. Group activities must be provided by staff
assigned responsibility for the activities.
12VAC30-120-1630. General requirements for [
enrolled ] providers.
A. Requests for participation will be screened by DMAS to
determine whether the provider applicant meets the requirements for
participation. Requests for participation must be accompanied by verification
of the facility's current licensure from
B. For DMAS to approve provider agreements with AAL Waiver providers, providers must meet staffing, financial solvency, and disclosure of ownership requirements.
Approved Enrolled providers must assure
freedom of choice to individuals, or their [ legally ]
authorized representative, 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;
Approved Enrolled providers must assure the
individual's freedom to refuse medical care, treatment, and services;
Approved Enrolled providers must accept
referrals for services only when staff is available to initiate and perform
such services on an ongoing basis;
Approved Enrolled providers must provide services
and supplies to individuals in full compliance with Title VI of the Civil
Rights Act of 1964, as amended (42 USC § 2000 et seq.), which prohibits
discrimination on the grounds of race, color, religion, 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 (29 USC § 794),
which prohibits discrimination on the basis of a disability; and the Americans
with Disabilities Act of 1990 (42 USC § 12101 et seq.), which provides
comprehensive civil rights protections to individuals with disabilities in
the areas of employment, public accommodations, state and local government
services, and telecommunications;
Approved Enrolled providers must provide
services and supplies to individuals of the same quality as are provided to the
Approved Enrolled providers must submit
charges to DMAS for the provision of services and supplies to individuals 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 beginning
with the individual's authorization date for the waiver services;
Approved Enrolled providers must use only
DMAS-designated forms for service documentation. The provider must not alter
the DMAS forms in any manner unless approval from DMAS is obtained prior to
using the altered forms. If there is no designated DMAS form for service
documentation, the provider must include all elements required by DMAS in the
provider's service documentation;
Approved Enrolled providers must use
DMAS-designated billing forms for submission of charges;
Approved Enrolled providers must perform no
direct marketing activities to Medicaid individuals;
Approved Enrolled providers must 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 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.
b. Policies regarding retention of records shall apply even if the provider discontinues operation. DMAS shall be notified in writing of the storage location and procedures for obtaining records for review should the need arise. The storage location, as well as the agent or trustee, shall be within the Commonwealth;
Approved Enrolled providers must furnish
information on request and in the form requested, to DMAS, the Office of 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
Approved Enrolled providers must 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
individuals receiving ] Medicaid;
13. Pursuant to 42 CFR § 431.300 et seq., 12VAC30-20-90, and any other applicable federal or state law, all providers shall hold confidential and use for authorized DMAS purposes only all medical assistance information regarding individuals 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;
Approved Enrolled providers must notify DMAS
in writing as at least 15 days before ownership or management of
the facility changes;
15. Pursuant to § 63.2-1606 of the Code of Virginia, if a
participating enrolled provider knows or suspects that an [ individual
using ] AAL Waiver services [
individual ] is being
abused, neglected, or exploited, the party having knowledge or suspicion of the
abuse, neglect, or exploitation must report this immediately from first
knowledge to the local DSS or adult protective services hotline as applicable;
16. In addition to compliance with the general conditions and requirements, all providers enrolled by DMAS shall adhere to the conditions of participation outlined in the individual provider participation agreements and in the applicable DMAS provider manual. DMAS shall conduct ongoing monitoring of compliance with provider participation standards and DMAS policies. A provider's noncompliance with DMAS policies and procedures may result in a retraction of Medicaid payment or termination of the provider agreement, or both;
17. Enrolled providers are responsible for complying with
§ 63.2-1720 of the Code of Virginia regarding criminal record checks.
All employees must have a satisfactory work record, as evidenced by references
from prior job experience, including no evidence of abuse, neglect, or
exploitation of [ persons who are ] incapacitated or older
and or children. The criminal record check shall be
available for review by DMAS staff who are authorized by the agency to review
these files. DMAS will not reimburse the provider for any services provided by
an employee who has committed a barrier crime as defined herein . Providers
are responsible for complying with § 63.2-1720 of the Code of Virginia
regarding criminal record checks; and
Approved Enrolled providers must immediately
notify DMAS, in writing, of any change in the information that the provider
previously submitted to DMAS. C. A provider shall have the right to appeal adverse
actions taken by DMAS. Provider appeals shall be considered pursuant to
12VAC30-10-1000 and 12VAC30-20-500 through 12VAC30-20-560. D. C. The Medicaid provider agreement shall
terminate pursuant to § 32.1-325 of the Code of Virginia upon
conviction of the provider of a felony pursuant to § 32.1-325 of the Code of
Virginia. A provider convicted of a felony in Virginia or in any other of
the 50 states, the District of Columbia, or the U.S. territories, must, within
30 days of the conviction, notify the Virginia Medicaid Program and relinquish
the provider agreement. E. D. Provider's Responsibility responsibility
for the Patient Information Form (DMAS-122). Medicaid LTC
Communication Form (DMAS-225). It shall be the responsibility of the
service provider to notify VDSS DSS and DMAS, in writing, when
any of the following circumstances occur:
1. AAL Waiver services are implemented;
2. An individual dies;
3. An individual is discharged from the [
provider facility ];
4. Any other circumstances (including hospitalization) that cause AAL Waiver services to cease or be interrupted for more than 30 days.
F. E. Termination of waiver services.
1. In a nonemergency situation, i.e., when the health and safety of the individual or provider personnel is not endangered, the participating provider shall give the individual or family/caregiver, or both, at least 30 days' written notification plus three days for mailing of the intent to discontinue services. The notification letter shall provide the reasons for and the effective date the provider is discontinuing services.
2. In an emergency situation when the health and safety of the individual or provider personnel is endangered, the participating provider must notify DMAS immediately prior to discontinuing services. The written notification period shall not be required. If appropriate, local DSS Adult Protective Services must also be notified immediately.
12VAC30-120-1640. Participation standards for provision of services.
A. Facilities must have a signed provider agreement approved by DMAS to provide AAL Waiver services.
B. The facility must provide a safe, secure environment for
recipients individuals ]. There may be one or
more self-contained special care units in a facility or the whole facility may
be a special care unit. Personalized care must be furnished to individuals who
reside in their own living units, with semi-private rooms limited to two
[ people individuals ] and [ a maximum of two
individuals sharing a bathroom bathrooms consistent with 22VAC40-72-890 ].
Care Support ] in a facility must
be furnished in a way that fosters the independence of each individual to
[ facilitate aging age ] in place. Routines of care
provision and service delivery must be consumer-driven individual-driven
to the maximum extent possible and treat each person individual
must be treated with dignity and respect.
D. The medical care of
must be under the direction and supervision of a licensed physician. This can
be the individual's private physician. The facility must ensure that residents
have appointments with their physicians at least annually, and additionally
as needed as determined by the physician.
1. Administrators of participating assisted living facilities
must meet the regulatory requirements as set forth by the Virginia Department
of Social Services
(22VAC40-71-60 et seq.) (22VAC40-72-191) and
the Board of Long-Term Care Administrators (18VAC95-20-10 through
18VAC95-20-471) [ (18VAC95-20) (18VAC95-30) ].
2. The administrator shall demonstrate knowledge, skills and abilities in the administration and management of an assisted living facility program including:
a. Knowledge and understanding of [
older adults who have impairments ] or [ persons individuals ]
b. Supervisory and interpersonal skills;
c. Ability to plan and implement the program; and
d. Knowledge of financial management sufficient to ensure program development and continuity.
3. The administrator shall demonstrate knowledge of supervisory and motivational techniques sufficient to:
a. Accomplish day-to-day work;
b. Train, support and develop staff; and
c. Plan responsibilities for staff to ensure that services are
provided to [
participants individuals ].
4. The administrator shall complete 20 hours of continuing
education annually to maintain and develop skills. This training shall be in
addition to first aid
, and CPR, or and orientation
training to be received upon commencement of employment.
Nursing staff Licensed health care professional
1. Each facility shall have at least one
(RN) or licensed practical nurse (LPN) under the supervision of an RN, LHCP
awake, on duty, and on-site in the facility for at least eight hours a day,
five days each week and on call 24 hours a day. The person on call must be
able to arrive at the facility within one hour. In addition, the
facility shall provide for emergency call coverage at all hours of the day and
RN LHCP is responsible for staff training,
resident assessment individual summaries, [ plans of care
individual service plans ], and medication oversight.
Assessments Individuals' summaries.
Comprehensive assessment. Admissions summary.
An RN LHCP must complete a comprehensive assessment an
admissions summary of each resident individual upon
admission. The comprehensive assessment admissions summary
includes the UAI and other relevant social, psychological, and medical
information. The comprehensive assessment admissions summary must
also include the physician's assessment information as contained in 22VAC40-71-150
L 22VAC40-72-40 and 22VAC40-72-440. The comprehensive assessment
admissions summary must be updated yearly and when a significant change
in [ an individual's ] health status or behavior occurs. The
information gathered during the comprehensive assessment preparation
of the admissions summary is used to create the resident's individual's
[ service ] plan [ of care ] as
contained in 22VAC40-71-170 C and D 22VAC40-72-40 and 22VAC40-72-440.
Plan of care Individual service plan ].
Based on the individual resident assessment specific individual's
admission summary and the UAI, the RN LHCP, in coordination
with other caregivers including the resident's individual's
authorized representative [ , as may be appropriate, ] shall:
(1) Develop the
resident's individual's [ service ]
plan [ of care ] and formulate interventions to address the
specific problems identified;
(2) Evaluate both the facility's implementation and the
individual's response to the plan of care; and
(3) Review and update the [ individual service ]
of care ] at least quarterly and more often when
necessary to meet the needs of the resident individual.
assessments summary. The RN or an
LPN, under the supervision of the RN, LHCP must complete a monthly assessment
summary. Significant changes documented on the monthly assessment
summary must be addressed in an updated [ individual service ]
plan [ of care ]. The comprehensive assessment admissions
summary information shall also be updated as needed. At a minimum, the
monthly assessment contains summary must contain information about
the following elements:
(1) Weight loss;
(4) Behavioral [
symptoms issues ];
(5) Adverse reactions to prescribed medications;
(7) Pressure ulcers;
(8) Fecal impaction;
(9) Cognitive changes;
(10) Change in diagnoses; and
(11) Change in levels of dependence in ADLs.
4. In a facility with fewer than 16 waiver recipients, the
facility may employ an RN as part time or as a contracted employee.
4. The facility's
RN LHCP may also serve
as the administrator. In all instances where the facility's RN LHCP
is assigned duties as an administrator, the facility shall assure that the RN
LHCP devotes sufficient time and effort to all clinical duties to secure
health, safety, and welfare of recipients individuals. Any facility having more than 16 waiver recipients must
employ full time an RN to be responsible for the clinical needs of the
recipients. G.Unit coordinator. 1. Facilities must have a unit coordinator, awake and
on-site in the unit, who will manage the daily routine operation of the
specialty unit. 2. The unit coordinator must be available to the facility 24
hours a day. 3. At a minimum, the unit coordinator must be a certified
nurse aide (CNA) with at least one year experience in a DMAS-approved assisted
living facility or nursing home or other setting that involves working with
vulnerable adults. 4. The unit coordinator may be an RN or an LPN who is
serving as the assisted living facility's daily nurse, the administrator, or
the activities director. 5. In the event the unit coordinator is not available, an
alternate qualified staff member may serve in this capacity. Each assisted
living facility must establish its own written protocol and assure that only
qualified staff fulfill this requirement. 6. In all instances where the facility's RN is assigned
other duties as an administrator, unit coordinator, or both, the facility must
assure that the RN devotes sufficient time and effort to all clinical duties. H. G. Structured activities program. There shall
be a designated employee responsible for managing or coordinating the
structured activities program. This employee shall be on site in the special
care unit at least 20 hours a week, shall maintain personal interaction with
the residents and familiarity with their needs and interests, and shall meet at
least one of the following qualifications:
1. Be a qualified therapeutic recreation specialist or activities professional;
2. Be eligible for certification as a therapeutic recreation specialist or an activities professional by a recognized accrediting body;
3. Have at least one year full-time work experience within the last five years in an activities program in an adult care setting;
4. Be a qualified occupational therapist or an occupational therapy assistant; or
5. Prior to or within six months of employment, have successfully completed 40 hours of VDSS-approved training.
I. Certified nurse aides H. Direct care staff.
In order to provide services in this waiver, the assisted living facility must
use certified nurse aides (CNA) in the specialty unit at all times staff
who comply with 22VAC40-72-250, 22VAC40-72-1110, and 22VAC40-72-1120 in
staffing the specialty care unit. J. I. The assisted living facility must have
sufficient qualified and trained staff to meet the needs of the [ residents
individuals living in the facility ] at all times. K. J. There must be at least [ two one
] awake direct care staff in the special care unit at all times and more if
dictated by the needs of the [ residents individuals living in
the special care unit, in accordance with 22VAC40-72-1110 ]. L. K. Training requirements for all staff.
1. All staff who have contact with [
living in the facility ], including the administrator, shall have
completed 12 hours of Alzheimer's or related dementia-specific training within
30 days of employment. The training must be conducted by a health care
educator, adult education professional, or a licensed professional, with
expertise in Alzheimer's or related dementia. The health care educator,
adult education professional, or licensed professional must be acting within
the scope of the requirements of his profession, and have
had at least 12 hours of training in the [ care support ]
of individuals with cognitive impairments due to Alzheimer's or related
dementia prior to performing the training, and have had a minimum of three
years experience in the health care or dementia fields. In addition to health
care educators and adult education professionals, licensed professionals
eligible to conduct this training may include [ , but shall not
necessarily be limited to ]: physicians, psychologists, registered
nurses, licensed practical nurses, occupational therapists, physical
therapists, speech-language therapists, licensed clinical social workers, or
licensed professional counselors.
2. All direct [
care support ] staff
must receive annual training in accordance with 22VAC40-71-630 22VAC40-72-250
and 22VAC40-72-260, with at least eight hours of training in the care of
[ residents individuals living ] with dementia and
medical nursing needs. This training may be incorporated into the existing
training program and must address the medical nursing needs specific to each
[ resident individuals living in the facility ] in the
special care unit. This training must also incorporate problem areas that may
include weight loss, falls, elopements, behavioral [ symptoms issues ],
and adverse reactions to prescribed medications. A health care educator, adult
education professional or licensed professional with expertise in dementia must
conduct this training. The health care educator, adult education
professional or licensed professional must be acting within the scope of his
profession and have had at least 12 hours of training in the care of
individuals with cognitive impairments due to dementia prior to performing the
training. 3. The individual conducting the training must have at least
three years of experience in the health care or dementia care field. In
addition to health care educators and adult education professionals, licensed
professionals eligible to conduct the training include: physicians,
psychologists, registered nurses, occupational therapists, physical therapists,
speech/language pathologists, licensed clinical social workers, and licensed
professional counselors. M. L. Documentation. The assisted living
facility shall maintain the following documentation for review by DMAS staff
for each [ individual living in the ] assisted living [ resident
1. All UAIs, authorization forms, [ individual service ]
of care ] and assessments summaries and
individuals' admissions completed for the [ resident individuals
living in the facility shall be ] maintained for a period not less
than six years from the [ recipient's waiver individual's ]
start of [ care service ] in that facility;
2. All written communication related to the provision of
care services ] between the facility and the
assessor, licensed health care professional, DMAS, VDSS, the [ recipient
waiver individual ], or other related parties; and
3. A log that documents each day that the [
waiver individual ] is present in the facility.
12VAC30-120-1650. Payment for services.
A. DMAS shall pay the facility a per diem fee for each [ individual
using the ] AAL Waiver [
recipient who has been
enrolled in and ] authorized to receive assisted living services.
Except for 14 days of leave each calendar year as described in subsection C of
this section, payment of the per diem fee is limited to the days in which the
[ recipient individual ] is physically present in the
B. The services that are provided as a part of the [
grant Auxiliary Grant ] rate pursuant to 22VAC40-25 22VAC40-25-40
will not be included for payment from the waiver.
C. Periods of absence from the assisted living facility.
1. An assisted living facility AAL Waiver bed may be held for
leave when the
resident's individual's [ plan of
care ISP ] provides for such leave. Leave includes visits with
relatives and friends or admission to a rehabilitation center for up to seven consecutive
days for an evaluation. Leave does shall not include periods of
absence due to an admission to a hospital or nursing facility.
is shall be limited to 14 cumulative
days in any 12-month period. Leave is resident individual
specific and is counted from the first occurrence of overnight leave that a
resident an individual takes. From that date, [ a resident
an individual ] has 14 days of leave available during the next 365
3. After the 14 days of leave have been exhausted and during
periods of absence due to a hospital or nursing facility admission, the
assisted living facility may choose to hold the bed for the
but DMAS will shall not pay for the service. The resident individual
or the resident's individual's authorized representative may
choose to pay to hold the bed by paying the assisted living facility directly
using other funds. The rate shall be negotiated between the resident's individual's
authorized representative and the assisted living facility, but shall not exceed
the auxiliary grant rate in effect at the time of the resident's individual's
4. During periods of absence for any reason, DMAS shall hold
the waiver slot for the
resident individual for a total of 30
consecutive days. If the resident's individual's absence exceeds
30 days, DMAS shall terminate AAL Waiver services and assign the slot to the
next [ person individual ] on the waiting list.
12VAC30-120-1660. Utilization review.
A. DMAS shall conduct
audits utilization reviews
of the services billed to DMAS and interview [ recipients individuals
living in the facility and the legally authorized representative ] to
ensure that services are being provided and billed in accordance with DMAS
policies and procedures.
DMAS will review all facilities providing conduct
quality management reviews of the services provided and interview recipients
for all facilities providing services in this waiver on a regular basis to
ensure the health and safety in this waiver. On a regular basis,
DMAS shall conduct quality management reviews of the services provided and
interview individuals for all facilities providing services in this waiver to
ensure the individuals' health and safety in this waiver. ] All
quality management and level of care reviews will be performed [ at
least annually ] and will be performed on site [ on a
regular basis ].
12VAC30-120-1670. Waiver waiting list.
DMAS shall maintain a waiting list for the purpose of
individuals' access to this waiver [
program ] once
all of the currently approved waiver slots have been filled. Individuals must
meet all waiver eligibility criteria in order to be placed on the waiting list.
Individuals may be removed from the waiting list because: (i) they request that
their names be removed; (ii) they [ expire die ];
or (iii) they are placed in an active slot and begin to receive services.
A. Providers shall have the right to appeal actions taken by DMAS. Provider appeals shall be considered pursuant to the Virginia Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia) and DMAS regulations at 12VAC30-10-1000 and 12VAC30-20-500 through 12VAC30-20-560.
B. Medicaid [
individuals ] shall have the right to appeal actions taken by DMAS.
Recipient appeals shall be considered pursuant to 12VAC30-110.
DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-120)
User's Guide: Mental Retardation: Definition,
, and Systems of Supports, 10th Edition, 2002, American Association
on Mental Retardation Intellectual and Developmental Disabilities.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DMS-IV-TR), 2000, American Psychiatric Association.
Underwriter's Laboratories Safety Standard 1635, Standard for Digital Alarm Communicator System Units, Third Edition, January 31, 1996, with revisions through August 15, 2005.
Underwriter's Laboratories Safety Standard 1637, Standard for Home Health Care Signaling Equipment, Fourth Edition, December 29, 2006.