Final Text
12VAC30-60-300. Nursing facility criteria. (Repealed.)
A. Medicaid-funded long-term care services may be provided
in either a nursing facility or community-based care setting. The criteria for assessing
an individual's eligibility for Medicaid payment of nursing facility care
consist of two components: (i) functional capacity (the degree of assistance an
individual requires to complete activities of daily living) and (ii) medical or
nursing needs. The criteria for assessing an individual's eligibility for
Medicaid payment of community-based care consist of three components: (i)
functional capacity (the degree of assistance an individual requires to
complete activities of daily living), (ii) medical or nursing needs and (iii)
the individual's risk of nursing facility placement in the absence of
community-based waiver services. In order to qualify for either Medicaid-funded
nursing facility care or Medicaid-funded community-based care, the individual
must meet the same criteria.
B. The preadmission screening process preauthorizes a
continuum of long-term care services available to an individual under the
Virginia Medical Assistance Program. Nursing Facilities' Preadmission
Screenings to authorize Medicaid-funded long-term care are performed by teams
composed by agencies contracting with the Department of Medical Assistance
Services (DMAS). The authorization for Medicaid-funded long-term care must be
rescinded by the nursing facility or community-based care provider or by DMAS
at any point that the individual is determined to no longer meet the criteria
for Medicaid-funded long-term care. Medicaid-funded long-term care services are
covered by the program for individuals whose needs meet the criteria established
by program regulations. Authorization of appropriate non-institutional services
shall be evaluated before nursing facility placement is considered.
C. Prior to an individual's admission, the nursing facility
must review the completed pre-admission screening forms to ensure that
appropriate nursing facility admission criteria have been documented. The
nursing facility is also responsible for documenting, upon admission and on an
ongoing basis, that the individual meets and continues to meet nursing facility
criteria. For this purpose, the nursing facility will use the Minimum Data Set
(MDS) The post admission assessment must be conducted no later than 14 days
after the date of admission and promptly after a significant change in the
resident's physical or mental condition. If at any time during the course of
the resident's stay, it is determined that the resident does not meet nursing
facility criteria as defined in the State Plan for Medical Assistance, the
nursing facility must initiate discharge of such resident. Nursing facilities
must conduct a comprehensive, accurate, standardized, reproducible assessment
of each resident's functional capacity and medical and nursing needs.
The Department of Medical Assistance Services shall conduct
surveys of the assessments completed by nursing facilities to determine that
services provided to the residents meet nursing facility criteria and that
needed services are provided.
D. The community-based provider is responsible for
documenting upon admission and on an ongoing basis that the individual meets
the criteria for Medicaid-funded long-term care.
E. The criteria for nursing facility care under the
Virginia Medical Assistance Program are contained herein. An individual's need
for care must meet these criteria before any authorization for payment by
Medicaid will be made for either institutional or non-institutional long-term
care services. The Nursing Home Pre-Admission Screening team is responsible for
documenting on the state-designated assessment instrument that the individual
meets the criteria for nursing facility or community-based waiver services and
for authorizing admission to Medicaid-funded long-term care. The rating of
functional dependencies on the assessment instrument must be based on the individual's
ability to function in a community environment, not including any
institutionally induced dependence.
12VAC30-60-301. Definitions.
The following words and terms as used in 12VAC30-60-302 through 12VAC30-60-315 shall have the following meanings unless the context clearly indicates otherwise:
"Activities of daily living" or "ADLs" means personal care tasks such as bathing, dressing, toileting, transferring, and eating or feeding. An individual's degree of independence in performing these activities is a part of determining appropriate level of care and service needs.
"Adult" means a person age 18 years or older who may need Medicaid-funded long-term services and supports (LTSS) or who becomes [ functionally ] eligible to receive Medicaid-funded LTSS.
"Appeal" means the processes used to challenge actions regarding services, benefits, and reimbursement provided by Medicaid pursuant to 12VAC30-110 and Part XII (12VAC30-20-500 et seq.) of 12VAC30-20.
"At risk" means the need for the level of care
provided in a hospital, nursing facility, or an intermediate care facility for
individuals with intellectual disability (ICF/IID) when there is reasonable
indication that the individual is expected to need the services in the near
future (that is, [ one month 30 days ]
or less) in the absence of home or community-based services.
"Child" means a person up to the age of 18 years who may need Medicaid-funded LTSS or who becomes [ functionally ] eligible to receive Medicaid-funded LTSS.
"Choice" means the individual is provided the option of either home and community-based waiver services or institutional services and supports, including the Program of All-Inclusive Care for the Elderly (PACE), if available and appropriate, after the individual has been determined likely to need LTSS.
"Communication" means all forms of sharing information and includes oral speech and augmented or alternative communication used to express thoughts, needs, wants, and ideas, such as the use of a communication device, interpreter, gestures, and picture or symbol communication boards.
[ "Community-based services" means
community-based waiver services or the Program of All-Inclusive Care for the
Elderly (PACE). ]
[ "Community-based services
provider" means a provider or agency enrolled with Virginia Medicaid to
offer services to individuals eligible for home and community-based waivers
services or PACE. ]
"Community-based team" or "CBT" means (i) a registered nurse or nurse practitioner; (ii) a social worker or other assessor designated by DMAS; and (iii) a physician. The CBT members are employees of, or contracted with, the Virginia Department of Health or the local department of social services.
[ "CSB" means Community Services Board. ]
"DARS" means the Virginia Department for Aging and Rehabilitative Services.
"Day" means calendar day unless specified otherwise.
"DBHDS" means the Virginia Department of Behavioral Health and Developmental Services.
"DMAS" means the Department of Medical Assistance Services.
"DMAS designee" means the public or private entity with an agreement with the Department of Medical Assistance Services to complete preadmission screenings pursuant to § 32.1-330 of the Code of Virginia.
"ePAS" means the DMAS automated system or a
DMAS-approved electronic record system for use by [ all ]
entities contracted by DMAS to perform screenings pursuant to §
32.1-330 of the Code of Virginia.
"Face-to-face" means an in-person meeting with the individual seeking Medicaid-funded LTSS.
"Feasible alternative" means a range of services that can be provided in the community via waiver or PACE, for less than the cost of comparable institutional care, in order to enable an individual to continue living in the community.
[ "Functional capacity" means the degree of independence that an individual has in performing ADLs, ambulation and instrumental ADLs as measured on the UAI and as used as a basis for differentiating levels of long-term care services. ]
[ "Functional eligibility" means the demonstrable degree to which an individual requires assistance with Activities of Daily Living. ]
[ "Home and community-based services" means community-based waiver services or the Program of All-Inclusive Care for the Elderly (PACE). ]
[ "Home and community-based services provider" means a provider or agency enrolled with Virginia Medicaid to offer services to individuals eligible for home and community-based waivers services or PACE. ]
"Home and community-based services waiver" [ , HCBS ] or "waiver services" means the range of community services and supports [ , including PACE, ] approved by the Centers for Medicare and Medicaid Services (CMS) pursuant to § 1915(c) of the Social Security Act to be offered to individuals as an alternative to institutionalization.
"Hospital team" means persons designated by the
hospital who are responsible for conducting and submitting the screening [ document
documents ] for inpatients to ePAS.
"Inpatient" means an individual who has a
physician's order for admission to an acute care hospital, rehabilitation
hospital, or a rehabilitation unit in an acute care hospital and shall not apply
to [ outpatient outpatients ] ,
patients in observation beds, and patients of the hospital's emergency
department.
"Local department of social services" or "LDSS" means the entity established under § 63.2-324 of the Code of Virginia by the governing city or county in the Commonwealth.
"Local health department" or "LHD" means the entity established under § 32.1-31 of the Code of Virginia.
"Long-term services and supports" or
"LTSS" means a variety of services that help individuals with health
or personal care needs and ADLs over a period of time that can be provided in
the home, the community, [ assisted living facilities, ]
or nursing facilities.
[ "Managed Care Organization" or ]
"MCO" [ or ] means
a health plan selected to participate in the Commonwealth's CCC Plus program
and that is a party to a contract with DMAS.
"Medicaid" means the program set out in the 42 USC § 1396 et seq. and administered by the Department of Medical Assistance Services consistent with Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia.
[ "Medical or nursing need" means (i) the individual's condition requires observation and assessment to ensure evaluation of needs due to an inability for self-observation or evaluation; (ii) the individual has complex medical conditions that may be unstable or have the potential for instability, or; (iii) the individual requires at least one ongoing medical or nursing service.]
"Medicare" means the Health Insurance for the Aged and Disabled program as administered by the Centers for Medicare and Medicaid Services pursuant to 42 USC 1395ggg.
[ "Minimum Data Set" or "MDS" means the evaluation form used by nursing facilities, as federally required, for the purpose of documenting ongoing level of care required for all of the NF's residents.]
"Nursing facility" or "NF" means any nursing home as defined in § 32.1-123 of the Code of Virginia.
[ "Ongoing" means continuous medical or nursing needs that shall not be temporary. ]
"Other assessor designated by DMAS" means an employee of the local department of social services holding the occupational title of family services specialist [ or an employee of a DMAS designee ] .
"Preadmission screening" or "screening"
means the [ face-to-face ] process to (i)
evaluate the functional, [ medical or ] nursing,
and social support needs of individuals referred for screening for certain
long-term care services requiring NF eligibility; (ii) assist individuals in
determining what specific services the individual needs; (iii) evaluate whether
a service or a combination of existing community services are available to meet
the individual's needs; and (iv) [ provide the
provision of ] a list to individuals of appropriate providers for
Medicaid-funded nursing facility or home and community-based services for those
individuals who meet nursing facility level of care.
[ "Primary account holder" means
the person who performs the initial web registrations for the screening entity
and establishes the security needed for accessing ePAS. ]
"Private pay individual" means individuals who
are not eligible for Medicaid or not expected to become eligible for Medicaid [ for
180 days within six months ] following admission.
"Program of All-Inclusive Care for the Elderly" or "PACE" means the community-based service pursuant to § 32.1-330.3 of the Code of Virginia.
[ "Provider" means an individual professional or an agency enrolled with Virginia Medicaid to offer services to eligible individuals. ]
"Referral for screening" means information obtained from an interested person or other third party having knowledge of an individual who may need Medicaid-funded LTSS and may include, for example, a physician, PACE provider, service provider, family member, or neighbor who is able to provide sufficient information to enable contact with the individual.
[ "Reimbursement" means the
determination that a submitted claim is completed accurately and completely and
the service is covered resulting in the payment by DMAS for the services
represented on the claims. ]
"Representative" means a person who is authorized to make decisions on behalf of the individual.
"Request date for screening" or "request date" means the date (i) that an individual, [ an emancipated child, ] the individual's representative, an adult protective services worker, child protective services worker, [ physician, ] or the managed care organization (MCO) care coordinator contacts the screening entity in the jurisdiction where the individual resides asking for assistance with LTSS, or (ii) for hospital inpatients, that a physician orders case management consultation or a hospital's case management service determines the need for LTSS upon discharge from the hospital.
"Request for screening" means (i) communication
from an individual, [ an emancipated child, ]
individual's representative, adult protective services worker, child
protective services worker, [ physician, or ] managed
care organization (MCO) care coordinator [ , or CSB support
coordinator ] , expressing the need for LTSS or (ii) for hospital inpatients,
a physician order for case management consultation or case management
determination of the need for LTSS upon discharge from a hospital.
"Residence" means [ the location in
which an individual is living ] , for example, an individual's
private home, apartment, assisted living facility, nursing facility, [ or ]
jail or correctional facility [ if the individual
to be screened is seeking Medicaid-funded LTSS and does not request an
alternative screening location as allowed in 12VAC30-60-305 A ] .
"Screening entity" means the hospital screening team, community-based team, or DMAS designee contracted to perform screenings pursuant to § 32.1-330 of the Code of Virginia.
"Significant change in condition" means a change in an individual's condition that is expected to last longer than 30 days and shall not include (i) short-term changes that resolve with or without intervention; (ii) a short-term illness or episodic event; or (iii) a well-established, predictive, cyclic pattern of clinical signs and symptoms associated with a previously diagnosed condition where an appropriate course of treatment is in progress.
"Submission" means the transmission of the
screening findings [ and receipt of successfully
processed results using via ] ePAS.
[ "Submission date" means the date
that the screening entity transmits to DMAS the screening findings using ePAS. ]
"Uniform Assessment Instrument" or "UAI" means the standardized multidimensional assessment instrument that is completed by the screening entity that assesses an individual's physical health, mental health, and psycho/social and functional abilities to determine if the individual meets the nursing facility level of care.
"VDH" means the Virginia Department of Health.
12VAC30-60-302. Access to Medicaid-funded long-term services and supports.
A. Medicaid-funded long-term services and supports (LTSS)
may be provided in either home and community-based or institutional-based settings.
To receive LTSS, the individual's condition shall first be evaluated using the
designated assessment instrument, the Uniform Assessment Instrument (UAI), and
other [ designated DMAS-designated ] forms.
Screening entities shall [ also ] use the DMAS-designated
forms ( [ UAI, ] DMAS-95, DMAS-96,
DMAS-97) [ and ] , if selecting nursing
facility placement, the DMAS-95 Level I (MI/IDD/RC) [ , as
appropriate, the DMAS-108 and DMAS-109 ] . If indicated by the
DMAS-95 Level I results, the individual shall be referred to DBHDS for
completion of the DMAS-95 Level II (for nursing facility placements only).
1. An individual's need for LTSS shall meet the established criteria (12VAC30-60-303) before any authorization for reimbursement by Medicaid [ or its designee ] is made for LTSS.
2. Appropriate [ home and ] community-based services shall be evaluated [ as an option for long term services and supports ] prior to consideration of nursing facility placement.
B. The evaluation shall be the screening as designated in § 32.1-330 of the Code of Virginia, which shall preauthorize a continuum of LTSS covered by Medicaid. [ These screenings shall be conducted face-to-face. ]
1. Such screenings, using the UAI, shall be conducted by teams of representatives of (i) hospitals for individuals (adults and children) who are inpatients; (ii) local departments of social services and local health departments, known herein as CBTs, for adults residing in the community and who are not inpatients; (iii) a DMAS designee for children residing in the community who are not inpatients; and (iv) a DMAS designee for adults residing in the community who are not inpatients and who cannot be screened by the CBT within 30 days of the request date. All of these entities shall be contracted with DMAS to perform this activity and be reimbursed by DMAS.
2. All screenings shall be comprehensive, accurate, standardized, and reproducible evaluations of individual functional capacities, medical or nursing needs, and[ whether the individual is at ] risk for institutional placement [ within 30 days of the screening ] .
C. Individuals shall not be required to be financially eligible for receipt of Medicaid or have submitted an application for Medicaid in order to be screened for LTSS [ for admission to either a NF or home and community-based services ].
D. Pursuant to § 32.1-330 of the Code of Virginia,
individuals shall be screened if they are [ financially ] eligible
for Medicaid or are anticipated to become [ financially ]
eligible for Medicaid reimbursement of their NF care within six months of NF
[ placement admission or Medicaid reimbursement
of home and community-based services and supports ] .
E. Special circumstances.
[ 1. Out-of-state hospitals shall not be
required to perform a screening for residents of the Commonwealth who are
inpatients. If a screening is needed and is requested by either the individual
or the individual's representative, individuals shall be screened upon
discharge from the out-of-state hospital by the CBT serving the locality in
which the individual resides. Screenings shall not be required for individuals
who transfer into a nursing facility in the Commonwealth from an out-of-state
nursing facility.
[ 2. Veterans and military hospitals located
in the Commonwealth that have inpatients who are residents of the Commonwealth
shall not be required to perform screenings and may refer, upon discharge, the
individual who requests a screening to the CBT serving the locality in which
the individual resides. Screenings shall not be required for individuals who
transfer to a nursing facility in the Commonwealth from a veterans or military
hospital.
[ 3. State facilities that are licensed by
DBHDS shall not be required to perform screenings of individuals who are receiving
their services. Individuals shall be referred, upon discharge from such state
facilities, to the CBT serving the locality in which the individual lives if
the facility anticipates an individual may need a screening.
[ 4. Hospitals shall not be required to
initiate screenings for inpatients who are determined by the hospital team to
be private pay individuals unless there is a request for a screening as
outlined in 12VAC30-60-304 C.
[ 5. Wilson Workforce Rehabilitation Center
(WWRC) staff shall perform screenings of the WWRC clients.
[ 6. A screening shall not be required for
enrollment in Medicaid hospice services as set out in 12VAC30-60-130 and home
health services as set out in 12VAC30-50-160. ]
[ 1. Private pay individuals who will not become financially eligible for Medicaid within six months from admission to a Virginia nursing facility shall not be required to have a screening in order to be admitted to the NF.
[ 2. Individuals who reside out-of-state and seek direct admission to a Virginia nursing facility shall not be required to have a screening. Individuals who need a screening for HCBS waiver or PACE programs and request the screening shall be screened by the CBT or DMAS designee, as appropriate, serving the locality in which the individual resides once the individual has relocated to the Commonwealth.
[ 3. Individuals who are inpatients in an out-of-state hospital, in-state or out-of-state veteran's hospital, or in-state or out-of-state military hospital and seek direct admission to a Virginia NF shall not be required to have a screening. Individuals who need a screening for HCBS waiver or PACE programs and request the screening shall be referred, upon discharge from one of the identified facilities, to the CBT or DMAS designee, as appropriate, serving the locality in which the individual resides once the individual has relocated to the Commonwealth.
[ 4. Individuals who are patients or residents of a state owned/operated facility that is licensed by DBHDS and seek direct admission to a Virginia NF shall not be required to have a screening. Individuals who need a screening for HCBS waiver or PACE and request the screening shall be referred, upon discharge from the facility, to the CBT or DMAS designee, as appropriate, serving the locality in which the individual resides.
[ 5. A screening shall not be required for enrollment in Medicaid hospice services as set out in 12 VAC 30-50-270 or home health services as set out in 12 VAC 30-50-160.
[ 6. Wilson Workforce Rehabilitation Center staff shall perform screenings of the WWRC clients. ]
[ G F ] . Failure to
comply with DMAS requirements, including competency and training requirements
applicable to staff, may result in retraction of Medicaid payments.
12VAC30-60-303. Preadmission screening Screening
criteria for Medicaid-funded long-term care services and
supports.
A. Functional [ dependency capacity]
alone is shall not be deemed sufficient to
demonstrate the need for nursing facility care [ or placement
admission ] or authorization for [ home and ]
community-based care services [ and supports ] .
An individual shall be determined to meet the nursing facility criteria
when:
1. The individual has both limited functional capacity [ and
, ] medical or nursing needs [ , and is at risk
of NF admission within 30 days ] according to the requirements of
this section; or
2. The individual is rated dependent in some functional limitations, but does not meet the functional capacity requirements, and the individual requires the daily direct services or supervision of a licensed nurse that cannot be managed on an outpatient basis (e.g., clinic, physician visits, home health services).
B. An individual shall only be considered to meet the
nursing facility criteria when both the functional capacity of the individual
and his medical or nursing needs meet the following requirements. Even when an
individual meets nursing facility criteria, placement in a noninstitutional
setting shall be evaluated before actual nursing facility placement is
considered In order to qualify for Medicaid-funded LTSS, the individual
shall meet the following criteria:
1. [ For Medicaid-funded nursing
facility services to be authorized, the screening entity shall document that
the individual has both functional and medical or nursing needs ] .
The criteria for screening an individual's eligibility for Medicaid
reimbursement of NF services shall consist of [ two
three ] components: (i) functional capacity [ ; ]
(ii) medical or nursing needs [ , and;
(iii) [ the individual ] is at risk of NF
admission within 30 days of the screening date ] . The rating of
functional dependency on the UAI shall be based on the individual's ability to
function in a community environment and exclude all institutionally induced
dependencies.
2. In order for Medicaid-funded community-based [ LTSS
services ] to be authorized, an individual shall
not be required to be physically admitted to a NF. The criteria for screening
an individual's eligibility for Medicaid reimbursement of community-based
services shall consist of three components: (i) functional capacity [ needs
(the degree of assistance an individual requires in order to complete ADLs),
; ] (ii) medical or nursing needs, and [ ; ]
(iii) the individual's risk of NF placement within 30 days in the
absence of community-based services.
1. C. Functional capacity.
a. 1. When documented on a completed
state-designated preadmission screening assessment instrument a UAI that
is completed in a manner consistent with the definitions of activities of daily
living (ADLs) and directions provided by DMAS for the rating of those
activities, individuals may be considered to meet the functional capacity
requirements for nursing facility care when one of the following describes
their functional capacity:
(1) a. Rated dependent in two to four of the Activities
of Daily Living ADLs, and also rated semi-dependent or dependent in
Behavior Pattern and Orientation, and semi-dependent [ or
dependent ] in Joint Motion or dependent in Medication Administration.
(2) b. Rated dependent in five to seven of the Activities
of Daily Living ADLs, and also rated dependent in Mobility.
(3) c. Rated semi-dependent [ or
dependent ] in two to seven of the Activities of Daily Living ADLs,
and also rated dependent in Mobility and Behavior Pattern and Orientation.
b. 2. The rating of functional [ dependencies
capacity ] on the preadmission screening assessment
instrument must shall be based on the individual's ability to
function in a community environment, not including any institutionally induced
dependence. The following abbreviations shall mean: I = independent; d =
semi-dependent; D = dependent; MH = mechanical help; HH = human help.
(1) a. Bathing.
(a) (1) Without help (I)
(b) (2) MH only (d)
(c) (3) HH only (D)
(d) (4) MH and HH (D)
(e) (5) Performed by Others (D)
(2) b. Dressing.
(a) (1) Without help (I)
(b) (2) MH only (d)
(c) (3) HH only (D)
(d) (4) MH and HH (D)
(e) (5) Performed by Others (D)
(f) (6) Is not Performed (D)
(3) c. Toileting.
(a) (1) Without help day or night (I)
(b) (2) MH only (d)
(c) (3) HH only (D)
(d) (4) MH and HH (D)
(e) (5) Performed by Others (D)
(4) d. Transferring.
(a) (1) Without help (I)
(b) (2) MH only (d)
(c) (3) HH only (D)
(d) (4) MH and HH (D)
(e) (5) Performed by Others (D)
(f) (6) Is not Performed (D)
(5) e. Bowel Function function.
(a) (1) Continent (I)
(b) (2) Incontinent less than weekly (d)
(c) (3) External/Indwelling Device/Ostomy --
self care (d)
(d) (4) Incontinent weekly or more (D)
(e) (5) Ostomy -- not self care (D)
(6) f. Bladder Function function.
(a) (1) Continent (I)
(b) (2) Incontinent less than weekly (d)
(c) (3) External device/Indwelling
Catheter/Ostomy -- self care (d)
(d) (4) Incontinent weekly or more (D)
(e) (5) External device -- not self care (D)
(f) (6) Indwelling catheter -- not self care (D)
(g) (7) Ostomy -- not self care (D)
(7) g. Eating/Feeding.
(a) (1) Without help (I)
(b) (2) MH only (d)
(c) (3) HH only (D)
(d) (4) MH and HH (D)
(e) (5) Spoon fed (D)
(f) (6) Syringe or tube fed (D)
(g) (7) Fed by IV or clysis (D)
(8) h. Behavior Pattern pattern
and Orientation orientation.
(a) (1) Appropriate or Wandering/Passive less
than weekly + Oriented (I)
(b) (2) Appropriate or Wandering/Passive less
than weekly + Disoriented -- Some Spheres (I)
(c) (3) Wandering/Passive Weekly/or more +
Oriented (I)
(d) (4) Appropriate or Wandering/Passive less
than weekly + Disoriented -- All Spheres (d)
(e) (5) Wandering/Passive Weekly/Some or more +
Disoriented -- All Spheres (d)
(f) (6) Abusive/Aggressive/Disruptive less than
weekly + Oriented or Disoriented (d)
(g) (7) Abusive/Aggressive/Disruptive weekly or
more + Oriented (d)
(h) (8) Abusive/Aggressive/Disruptive +
Disoriented -- All Spheres (D)
(9) i. Mobility.
(a) (1) Goes outside without help (I)
(b) (2) Goes outside MH only (d)
(c) (3) Goes outside HH only (D)
(d) (4) Goes outside MH and HH (D)
(e) (5) Confined -- moves about (D)
(f) (6) Confined -- does not move about (D)
(10) j. Medication Administration administration.
(a) (1) No medications (I)
(b) (2) Self administered -- monitored less than
weekly (I)
(c) (3) By lay persons, Administered/Monitored
(D)
(d) (4) By Licensed/Professional nurse
Administered/Monitored (D)
(11) k. Joint Motion motion.
(a) (1) Within normal limits or instability
corrected (I)
(b) (2) Limited motion (d)
(c) (3) Instability -- uncorrected or immobile
(D)
c. D. Medical or nursing needs. An individual
with medical or nursing needs is an individual whose health needs require
medical or nursing supervision or care above the level that could be provided
through assistance with Activities of Daily Living ADLs, Medication
Administration medication administration, and general supervision
and is not primarily for the care and treatment of mental diseases. Medical or nursing
supervision or care beyond this level is required when any one of the following
describes the individual's need for medical or nursing supervision:
(1) 1. The individual's medical condition
requires observation and assessment to [ assure ensure ]
evaluation of the [ person's individual's ]
need for modification of treatment or additional medical procedures to
prevent destabilization, and the person has demonstrated an inability to self
observe or evaluate the need to contact skilled medical professionals;
(2) 2. Due to the complexity created by the
[ person's individual's ] multiple,
interrelated medical conditions, the potential for the individual's medical
instability is high or medical instability exists; or
(3) 3. The individual requires at least one
ongoing medical or nursing service. The following is a nonexclusive list of
medical or nursing services that may, but need not necessarily, indicate a need
for medical or nursing supervision or care:
(a) a. Application of aseptic dressings;
(b) b. Routine catheter care;
(c) c. Respiratory therapy;
(d) d. Supervision for adequate nutrition and
hydration for individuals who show clinical evidence of malnourishment or
dehydration or have recent history of weight loss or inadequate hydration that,
if not supervised, would be expected to result in malnourishment or
dehydration;
(e) e. Therapeutic exercise and positioning;
(f) f. Routine care of colostomy or ileostomy or
management of neurogenic bowel and bladder;
(g) g. Use of physical (e.g., side rails,
poseys, locked wards) and/or or chemical restraints, or both;
(h) h. Routine skin care to prevent pressure
ulcers for individuals who are immobile;
(i) i. Care of small uncomplicated pressure
ulcers and local skin rashes;
(j) j. Management of those with sensory,
metabolic, or circulatory impairment with demonstrated clinical evidence of
medical instability;
(k) k. Chemotherapy;
(l) l. Radiation;
(m) m. Dialysis;
(n) n. Suctioning;
(o) o. Tracheostomy care;
(p) p. Infusion therapy; or
(q) q. Oxygen.
d. Even when an individual meets nursing facility criteria,
provision of services in a noninstitutional setting shall be considered before
nursing facility placement is sought.
C. E. When assessing an individual 21 years
of age or younger screening a child, the teams who are screening
entity who is conducting preadmission screenings [ the ]
screening for long-term care services LTSS shall utilize the electronic
Uniform Assessment Instrument (UAI) interpretive guidance as contained
referenced in DMAS' Medicaid Memo dated October 3, 2012, entitled
"Development of Special Criteria for the Purposes of Pre-Admission
Screening," November 22, 2016, entitled "Reissuance of
the Pre-Admission Screening (PAS) Provider Manual, Chapter IV," which
can be accessed on the DMAS website at https://www.virginiamedicaid.dmas.virginia.gov/.
12VAC30-60-304. Requests [ and referrals ] for screening for adults and children living in the community and adults and children in hospitals.
A. Screenings for adults living in the community. Screenings
for adults who are residing in the community but who are not inpatients shall
be completed and submitted [ (submission date) ]
by the CBT to ePAS [ within 30 days of the request
date for screening ] . [ If the individual,
or any of the other persons permitted to make such requests, requests a
screening, the CBT shall be required to perform the requested screening;
otherwise, CBTs shall not be required to screen individuals who are not
expected to become financially eligible for [ Medicaid
Medicaid-funded reimbursement of this LTSS within
six months of the screening. ]
1. Requests for screenings shall be accepted from either an individual, the individual's representative, an adult protective service worker, [ the individual's physician, ] or an MCO care coordinator having an interest in the individual. The CBT in the jurisdiction where the individual resides shall conduct such screening. For the screening to be scheduled by the CBT, the individual shall either agree to participate or, if refusing, shall be under order of a court of appropriate jurisdiction to have a screening.
a. The LDSS or LHD in receipt of the request for a screening shall contact the individual or his representative within seven days of the request date for screening to schedule a screening with the individual and any other persons whom the individual selects to attend the screening.
b. When the CBT has not scheduled a screening to occur
within 21 days of the request date for screening, and the screening is not
anticipated to be complete within 30 days of the request date for screening due
to the screening entity's inability to conduct the screening, the LDSS and LHD
shall, no later than seven days after the request date for screening, notify
DARS and VDH staff designated for technical assistance. [ After
contact with the LDSS and LHD, if DARS and VDH confirm that the screening
entity is unable to complete the screening within 30 days of the request date
for screening, the designated VDH staff shall refer the CBT and screening
request to the DMAS designee for scheduling of a screening and submission of
documentation. ]
2. Referrals for screenings may also be accepted by LDSS or
LHD from an interested person having knowledge of an individual who may need
LTSS. When the LDSS or LHD receives such a referral, the LDSS or LHD shall
obtain sufficient information from the referral source to initiate contact with
the individual or his representative to discuss the [ preadmission ]
screening process. Within seven days of the referral date, the LDSS or
LHD shall contact the individual or his representative to determine if the
individual is interested in receiving LTSS and would participate in the
screening. If the LDSS or LHD is unable to contact the individual or his
representative, it shall document the attempt to contact the individual or his
representative using the method adopted by the CBT.
a. After contact with the individual or his representative, or if the LDSS or LHD is unable to contact the individual or his representative, the LDSS or LHD shall advise the referring interested person that contact or attempt to contact has been made in response to the referral for screening.
b. Information about the results of the contact shall only
be shared [ by the LDSS or LHD ] with the
interested person who made the referral [ with either
when the LDSS or LHD has ] the individual's written consent
or the written consent of his legal representative who has such authority on
behalf of the individual.
B. Screenings for children living in the community.
Screenings for children who are residing in the community but who are not
inpatients shall be completed and submitted [ to
via ] ePAS [ (this shall be considered
the submission date as defined herein) within 30
days of the request date for screening ] . [ If the
individual or parent/guardian, or any of the other persons permitted to make
such requests, requests a screening, the DMAS designee shall perform the
requested screening; otherwise, the DMAS designee shall not be required to
screen individuals who are not expected to become financially eligible for [ Medicaid
Medicaid-funded ] LTSS within six months of the screening.
]
1. A child who is residing in the community and is not an
inpatient shall receive a screening from a DMAS designee. [ The
CBT shall forward requests for such screenings directly to the DMAS designee.
The DMAS designee may receive requests for screenings directly. Any
requests for screenings for a child received by the CBT shall be forwarded
directly to the DMAS designee. For the screening to be scheduled by the CBT,
the child shall either agree to participate or, if refusing, shall be under
order of a court of appropriate jurisdiction to have a screening. ]
2. The request for screening of a child residing in the
community shall [ initiate be accepted ]
from the parent, [ legal guardian, ] the
entity having legal custody of that child, an emancipated child, [ a
physician, ] an MCO care coordinator, or a child
protective service worker having an interest in the child.
3. Referrals for screenings may also be accepted from an interested person having knowledge of a child who may need LTSS. The process, timing, and limitations on the sharing of the results for referrals for screenings for children shall be the same as that set out for adults in subdivision A 2 of this section.
C. Screenings in hospitals for adults and children who are
inpatients. Screenings in hospitals shall be completed when an adult or
child who is an inpatient may need LTSS upon discharge or when the [ inpatient
individual ] , [ MCO, ] or
representative, requests a screening.
1. As a part of the discharge planning process, the hospital team shall [ also ] complete a face-to-face screening when:
a. The individual's physician, in collaboration with the
individual or the individual's representative if there is one [ , ]
makes a request of the hospital team. If the individual is a child,
the screening shall be completed when the individual's physician, in
collaboration with the child's parent, [ legal guardian, ]
the entity having legal custody of the child, [ or ]
the emancipated child [ , APS/CPS worker, or MCO care coordinator ]
makes a request of the hospital team; or
b. The individual, the individual's representative if there
is one, parent, [ legal guardian, ] entity having legal
custody, [ or ] emancipated child
[ , APS/CPS worker, or MCO care coordinator ] requests
a consultation with hospital case management.
2. [ Such When there is a
request, such ] individual shall receive a screening conducted by
the hospital team regardless of [ the primary payer source
(e.g., Medicare, health maintenance organization) and
whether or not if ] they are eligible for Medicaid
or are anticipated to become eligible for Medicaid within six months after admission
to a NF.
[ 3. The hospital team shall exclude all institutionally-induced dependencies from the face-to-face screening documentation. ]
[ D. Screenings shall be submitted via e-PAS within 30 days of the screening request. ]
Statutory Authority
12VAC30-60-305. Screenings in the community and hospitals for Medicaid-funded long-term services and supports.
A. Community screenings for adults.
1. [ Eligibility Medical or
nursing and functional eligibility ] for Medicaid-funded LTSS
shall be determined by the CBT after completion of a screening of the
individual's needs and available supports. The CBT shall [ document
a screening of consider ] all the supports available for
that individual in the community (i.e., the immediate family, other relatives,
other community resources [ ) ] , and other services in
the continuum of LTSS [ ) ] . The screening
shall be documented on the [ designated DMAS
DMAS-designated ] forms identified in 12VAC30-60-306.
2. Screenings shall be completed in the individual's
residence unless the residence presents a safety risk for the individual or the
CBT, or unless the individual or the representative requests that the screening
be performed in an alternate location within the same jurisdiction. The individual
shall be permitted to have another person [ or persons ]
present at the time of the screening. Other than situations when a
court has issued an order for a screening, the individual shall also be
afforded the right to refuse to participate. The CBT shall determine the
appropriate degree of participation and assistance given by other persons to
the individual during the screening and accommodate the individual's
preferences to the extent feasible.
3. The CBT shall:
a. Observe the individual's ability to perform [ appropriate ] ADLs according to 12VAC30-60-303 and consider the individual's communication or responses to questions or his representative's communication or responses;
b. Observe, assess, and report the individual's medical [ , nursing, and functional ] condition. This information shall be used to ensure accurate and comprehensive evaluation of the individual's need for modification of treatment or additional medical procedures to prevent destabilization even when the individual has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals;
c. Identify the medical or nursing needs, [
or both, and functional needs ] of the individual;
and
d. Consider services and settings that may be needed by the individual in order for the individual to safely perform ADLs.
4. Upon completion of the screening and in consideration of
the communication from the individual or his representative, if appropriate,
and observations obtained during the screening, the CBT shall determine whether
the individual meets the criteria set out in 12VAC30-60-303. If the individual
meets the criteria for LTSS, the CBT shall inform [ the
individual or his representative, if appropriate, of this determination
in writing ] and provide choice [ to the
individual and his representative, if appropriate, ] of
the feasible alternatives[ , such as PACE or home and
community-based waiver services, ] to placement in a NF.
5. If waiver services or PACE, where available, are
declined, the reason for [ the declination declining ]
shall be recorded on the DMAS-97, Individual Choice - Institutional Care or
Waiver Services Form. The CBT shall have this document signed by either the
individual or his representative, if appropriate. In addition to the electronic
document, a paper copy of the DMAS-97 form with the individual's or his
representative's signature shall be retained in the individual's record by the
screening entity.
6. If the individual meets criteria and selects [ home and ] community-based services, the CBT shall also document that the individual is at risk of NF placement in the absence of [ home and ] community-based services by finding that at least one of the following conditions exists:
a. The individual has been cared for in the home prior to
the screening and evidence is available demonstrating a deterioration in the
individual's health care condition, a significant change in condition, or a
change in available supports [ preventing previous services
and supports from meeting the individual's needs ] . Examples
of such evidence may include (i) recent hospitalizations, (ii) attending
physician documentation, or (iii) reported findings from medical or social
service agencies.
b. There has been no significant change in condition or available support but evidence is available that demonstrates the individual's functional, medical, or nursing needs are not being met. Examples of such evidence may include (i) recent hospitalizations, (ii) attending physician documentation, or (iii) reported findings from medical or social service agencies.
7. If the individual selects NF placement, the CBT shall follow the Level I identification and Level II evaluation process as outlined in Part III (12VAC30-130-140 et seq.) of 12VAC30-130.
8. If the CBT determines that the individual does not meet
the criteria set out in 12VAC30-60-303, the CBT shall notify [ in
writing ] the individual [ and
or ] the individual's representative, as may be appropriate, [ in
writing ] that LTSS are being denied for the individual. The denial
notice shall include the individual's right to appeal consistent with DMAS
client appeals regulations (12VAC30-110).
9. For those screenings conducted in accordance with clause iv of 12VAC30-60-302 B 1, the DMAS designee shall follow the process outlined in this subsection.
B. Community screenings for children.
1. [ Eligibility Medical or
nursing and functional eligibility ] for Medicaid-funded LTSS
shall be determined by the DMAS designee after completion of a screening of the
child's needs and available supports. The DMAS designee shall [ document
a screening of consider ] all the supports
available for that child in the community (i.e., the immediate family, other
community resources, and other services in the continuum of LTSS). The
screening shall be documented on the designated DMAS forms identified in
12VAC30-60-306.
2. Upon receipt of a screening request, the DMAS designee shall schedule an appointment to complete the requested screening. Community settings where screenings may occur include the child's residence, other residences, children's residential facilities, or other settings with the exception of acute care hospitals, rehabilitation units of acute care hospitals, and rehabilitation hospitals.
3. The DMAS designee shall:
a. Determine the appropriate degree of participation and assistance given by other persons to the individual during the screening in recognition of the individual's preferences to the extent feasible.
b. Observe the child's ability to perform [ appropriate ] ADLs according to 12VAC30-60-303 and consider the parent's, legal guardian's, or emancipated child's communications or responses to questions;
c. Observe, assess, and report the child's medical [ or nursing, and functional ] condition. This information shall be used to ensure accurate and comprehensive evaluation of the child's need for modification of treatment or additional medical procedures to prevent destabilization even when the child has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals;
d. Identify the medical or nursing
[ , and functional ] needs [ , or
both, ] of the child; and
e. Consider services and settings that may be needed by the child in order for the child to safely perform ADLs in the community.
4. Upon completion of the screening and in consideration of
the communication from the child or his representative, if appropriate, and
observations obtained during the screening, the DMAS designee shall determine
whether the child meets the criteria set out in 12VAC30-60-303. If the child
meets the criteria for [ Medicaid-funded ] LTSS,
the DMAS designee shall inform [ the child and his representative,
if appropriate, of this determination in writing ] and provide
choice [ to the child and his representative, if
appropriate, ] of the feasible alternatives[ ,
such as PACE or home and community based waiver services, ] to NF
placement.
5. If waiver services are declined, the reason for declining
shall be recorded on the DMAS-97, Individual Choice - Institutional Care or
Waiver Services Form. The DMAS designee shall have this document signed by
either the [ emancipated ] child or his
representative [ , if appropriate ] . In addition
to the electronic document, a paper copy of the DMAS-97 form with the child's
or his representative's signature shall be retained in the child's record by
the screening entity.
6. If the child meets criteria and selects [ home and ] community-based services, the DMAS designee shall also document that the individual is at risk of NF placement in the absence of [ home and ] community-based services by finding that at least one of the following conditions exists:
a. The child has been cared for in the home prior to the
screening and evidence is available demonstrating a deterioration in the
child's health care condition, a significant change in condition, or a change
in available supports [ preventing previous services and
supports from meeting the child's needs ] . Examples of such
evidence may include (i) recent hospitalizations, (ii) attending physician
documentation, or (iii) reported findings from medical or social service
agencies.
b. There has been no significant change in condition or available support but evidence is available that demonstrates the child's functional, medical, or nursing needs are not being met. Examples of such evidence may include (i) recent hospitalizations, (ii) attending physician documentation, or (iii) reported findings from medical or social service agencies.
7. If the parent, [ legal guardian, ] entity having legal custody of the child, or emancipated child selects NF placement, the DMAS designee shall follow the Level I identification and Level II evaluation process as set out in Part III (12VAC30-130-140 et seq.) of 12VAC30-130.
8. If the DMAS designee determines that the child does not
meet the criteria to receive [ Medicaid-funded ] LTSS
as set out in 12VAC30-60-303, the DMAS designee shall notify [ in
writing ] the parent, [ legal guardian, ]
entity having legal custody of the child, or the emancipated child and
representative, as may be appropriate, [ in writing ]
that [ Medicaid-funded ] LTSS are being denied
for the child. The denial notice shall include the child's right to appeal
consistent with DMAS client appeals regulations (12VAC30-110).
C. Screenings for adults and children in hospitals. For the purpose of this subsection, the term "individual" shall mean either an adult or a child.
1. [ Eligibility Medical or
nursing and functional eligibility ] for Medicaid-funded LTSS
shall be determined by the hospital screening team after completion of a
screening of the individual's [ medical or nursing and
functional ] needs and available supports. The hospital
screening team shall [ document a screening of
consider ] all the supports available for that individual in
the community (i.e., the immediate family, other relatives, other community
resources, and other services in the continuum of LTSS).
2. Screenings shall be completed in the hospital prior to
discharge. The individual shall be permitted to have another person [ or
persons ] present at the time of the screening. [ Other
than situations Except ] when a court has issued
an order for a screening, the individual shall also be afforded the right to
refuse to participate. The hospital screening team shall determine the
appropriate degree of participation and assistance given by other persons to
the individual during the screening and accommodate the individual's
preferences to the extent feasible.
3. The hospital screening team shall:
a. Observe the individual's ability to perform [ appropriate ] ADLs according to 12VAC30-60-303, excluding all institutionally induced dependencies, and consider the individual's communication or responses to questions or his representative's communication or responses;
b. Observe, assess, and report the individual's medical [ or nursing, and functional ] condition. This information shall be used to ensure accurate and comprehensive evaluation of the individual's need for modification of treatment or additional medical procedures to prevent destabilization even when the individual has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals;
c. Identify the medical [ or , ]
nursing [ , and functional ] needs
[ , or both, ] of the individual; and
d. Consider services and settings that may be needed by the individual in order for the individual to safely perform ADLs.
4. Upon completion of the screening and in consideration of
the communication from the individual or his representative, if appropriate,
and observations obtained during the screening, the hospital screening team
shall determine whether the individual meets the criteria set out in
12VAC30-60-303. If the individual meets the criteria for [ Medicaid-funded ]
LTSS, the hospital screening team shall inform [ and
provide choice to ] the individual [ and
or ] his representative, if appropriate, [ of
this determination in writing and provide choice ] [ to
the individual and his representative, if appropriate ] of
the feasible alternatives [ , such as PACE or home and community
based waiver services, ] to placement in a NF.
5. If waiver services or PACE, where available, are
declined, the reason for [ the declination
declining ] shall be recorded on the DMAS-97, Individual Choice -
Institutional Care or Waiver Services Form. The hospital screening team shall
have this document signed by either the individual or his representative, if
appropriate. In addition to the electronic document, a paper copy of the
DMAS-97 form with the individual's or his representative's signature shall be
retained in the individual's record.
6. If the individual meets criteria and selects [ home and ] community-based services, the hospital screening team shall also document that the individual is at risk of NF placement in the absence of [ home and ] community-based services by finding that at least one of the following conditions exists:
a. Prior to the inpatient admission, the individual was
cared for in the home and evidence is available demonstrating a deterioration
in the individual's health care condition, a significant change in condition,
or a change in available supports [ preventing previous
services and supports from meeting the individual's needs ] .
Examples of such evidence may include (i) recent hospitalizations, (ii)
attending physician documentation, or (iii) reported findings from medical or
social service agencies.
b. There has been no significant change in condition or available support but evidence is available that demonstrates the individual's functional, medical, or nursing needs are not being met. Examples of such evidence may include (i) recent hospitalizations, (ii) attending physician documentation, or (iii) reported findings from medical or social service agencies.
7. If the individual selects NF placement, the hospital screening team shall follow the Level I identification and Level II evaluation process as outlined in Part III (12VAC30-130-140 et seq.) of 12VAC30-130.
8. If the hospital screening team determines that the
individual does not meet the criteria set out in 12VAC30-60-303, the hospital
screening team shall notify [ in writing ] the
individual [ and or ] the
individual's representative, as may be appropriate, [ in
writing ] that LTSS are being denied for the individual. The denial
notice shall include the individual's right to appeal consistent with DMAS
client appeals regulations (12VAC30-110).
12VAC30-60-306. Submission of screenings.
A. The screening entity shall complete and submit the
following forms to DMAS electronically [ on via
] ePAS:
1. DMAS-95 - MI/IDD/RC (Supplemental Assessment Process Form Level I) [ , as appropriate ] ;
2. DMAS-96 (Medicaid-Funded Long-Term Care Service
Authorization Form) [ , as appropriate ] ;
3. DMAS-97 (Individual Choice - Institutional Care or Waiver
Services) [ , as applicable ; [ and ]
4. UAI (Uniform Assessment Instrument) .
;
[ 5. DMAS-108 (Tech Waiver Adult Referral); and ]
[ 6. DMAS-109 (Tech Waiver Pediatric Referral. ]
B. For screenings performed in the community, the screening
entity shall submit to DMAS [ on via ] ePAS
each screening form listed in subsection A of this section within 30 days of
the individual's request date for screening.
C. For screenings performed in a hospital, the hospital
team shall submit to DMAS [ on via ] ePAS
each screening form listed in subsection A of this section, which shall be
completed prior to the individual's discharge. For individuals who will be
admitted to a Medicare-funded skilled NF or to a Medicare-funded rehabilitation
hospital (or rehabilitation unit) directly upon discharge from the hospital,
the hospital screener shall have up to an additional three days post-discharge
to submit the screening forms via ePAS.
12VAC30-60-307. Summary of pre-admission nursing facility
criteria. (Repealed.)
A. An individual shall be determined to meet the nursing
facility criteria when:
1. The individual has both limited functional capacity and
requires medical or nursing management according to the requirements of
12VAC30-60-303, or
2. The individual is rated dependent in some functional
limitations, but does not meet the functional capacity requirements, and the
individual requires the daily direct services or supervision of a licensed
nurse that cannot be managed on an outpatient basis (e.g., clinic, physician
visits, home health services).
B. An individual shall not be determined to meet nursing
facility criteria when one of the following specific care needs solely
describes his or her condition:
1. An individual who requires minimal assistance with
activities of daily living, including those persons whose only need in all
areas of functional capacity is for prompting to complete the activity;
2. An individual who independently uses mechanical devices
such as a wheelchair, walker, crutch, or cane;
3. An individual who requires limited diets such as a
mechanically altered, low salt, low residue, diabetic, reducing, and other
restrictive diets;
4. An individual who requires medications that can be
independently self-administered or administered by the caregiver;
5. An individual who requires protection to prevent him from
obtaining alcohol or drugs or to address a social or environmental problem;
6. An individual who requires minimal staff observation or
assistance for confusion, memory impairment, or poor judgment;
7. An individual whose primary need is for behavioral
management which can be provided in a community-based setting;
12VAC30-60-308. Nursing facility admission and level of care determination requirements.
Prior to an individual's admission, the NF shall review the
completed screening forms to ensure that applicable NF admission criteria have
been met [ , and ] documented
[ and submitted via e-PAS unless the individual meets any of the
special circumstances [ as ] set out in 12 VAC
30-60-302 E. NFs shall not accept paper screening forms as proof that
admission criteria have been met and documented ] .
12VAC30-60-310. [Reserved] Competency training and
testing requirements.
By [ no later than December
31, 2018 June 30, 2019 ] , each person performing screenings on
behalf of a screening entity shall complete required training and competency [ assessments
tests ] . A score of at least 80% on each module [ for
each person who is required to [ sign off give
final approval ] on screenings on behalf of the screening
entity ] shall constitute satisfactory competency [ assessments
test ] results. The most current competency [ assessment
test ] results shall be kept in the screening entity's personnel
records for each person performing screenings for the screening entity. Such
documentation results shall be provided to DMAS upon its request.
1. All persons [ performing
who are required by the screening entity to give final approval of ] screenings
shall complete the DMAS-approved training and pass the corresponding competency
[ assessment tests ] with a score of at
least 80% for each module of the training prior to performing screenings. [ This
training shall be repeated no less than every three years resulting in a score
of at least 80% on each module. ]
[ 2. Upon successful completion of the initial
training, each person who is required to [ sign off on
give final approval of ] screenings on behalf of the
screening entity shall complete the shortened refresher course no less than
every three years [ . resulting in a A ]
score of at least 80% on the refresher module [ shall be required
for a person to continue to perform screenings or give final approval of
screenings on behalf of the screening entity ] . ]
[ 2.3. ] Failure
to satisfy the training and competency [ assessment
tests ] requirements may result in the retraction of Medicaid
payment.
12VAC30-60-312. Evaluation to determine eligibility for
Medicaid payment of nursing facility or home and community-based care services.
(Repealed.)
A. The screening team shall not authorize Medicaid-funded nursing
facility services for any individual who does not meet nursing facility
criteria. Once the nursing home preadmission screening team has determined
whether or not an individual meets the nursing facility criteria, the screening
team must determine the most appropriate and cost-effective means of meeting
the needs of the individual. The screening team must document a complete
assessment of all the resources available for that individual in the community
(i.e., the immediate family, other relatives, other community resources and
other services in the continuum of long-term care which are less intensive than
nursing facility level-of-care services). The screening team shall be
responsible for preauthorizing Medicaid-funded long-term care according to the
needs of each individual and the support required to meet those needs. The
screening team shall authorize Medicaid-funded nursing facility care for an
individual who meets the nursing facility criteria only when services in the
community are either not a feasible alternative or the individual or the
individual's representative rejects the screening team's plan for community
services. The screening team must document that the option of community-based
alternatives has been explained, the reason community-based services were not
chosen, and have this document signed by the client or client's primary
caregivers.
B. The screening team shall authorize community-based
waiver services only for an individual who meets the nursing facility criteria
and is at risk of nursing home placement without waiver services. Waiver
services are offered to such an individual as an alternative to avoid nursing
facility admission pursuant to 42 CFR 441.302 (c)(1).
C. Federal regulations which govern Medicaid-funded home
and community-based services require that services only be offered to
individuals who would otherwise require institutional placement in the absence
of home- and community-based services. The determination that an individual
would otherwise require placement in a nursing facility is based upon a finding
that the individual's current condition and available support are insufficient
to enable the individual to remain in the home and thus the individual is at
risk of institutionalization if community-based care is not authorized. The
determination of the individual's risk of nursing facility placement shall be
documented either on the state-designated pre-admission screening assessment or
in a separate attachment for every individual authorized to receive
community-based waiver services. To authorize community-based waiver services,
the screening team must document that the individual is at risk of nursing
facility placement by finding that one of the following conditions is met:
1. Application for the individual to a nursing facility has
been made and accepted;
2. The individual has been cared for in the home prior to
the assessment and evidence is available demonstrating a deterioration in the
individual's health care condition or a change in available support preventing
former care arrangements from meeting the individual's need. Examples of such
evidence may be, but shall not necessarily be limited to:
a. Recent hospitalizations;
b. Attending physician documentation; or
c. Reported findings from medical or social service
agencies.
3. There has been no change in condition or available
support but evidence is available that demonstrates the individual's
functional, medical and nursing needs are not being met. Examples of such
evidence may be, but shall not necessarily be limited to:
a. Recent hospitalizations;
b. Attending physician documentation; or
c. Reported findings from medical or social service
agencies.
12VAC30-60-313. Individuals determined to not meet criteria for Medicaid-funded long-term services and supports.
[ An Notwithstanding 12 VAC
30-60-302 E, an ] individual shall be determined not to meet [ the
medical or nursing and functional ] criteria for Medicaid-funded
LTSS when [ there is no screening or MDS to document the
individual meets the medical or nursing and functional critiera
or when ] one of the following specific care needs solely
describes the individual's condition:
1. The individual requires minimal assistance with ADLs, including those individuals whose only need in all areas of functional capacity is for prompting to complete the activity;
2. The individual independently uses mechanical devices such as a wheelchair, walker, crutch, or cane;
3. The individual requires limited diets such as a mechanically altered, low-salt, low-residue, diabetic, reducing, or other restrictive diets;
4. The individual requires medications that can be independently self-administered or administered by the caregiver;
5. The individual requires protection to prevent him from obtaining alcohol or drugs or to address a social or environmental problem;
6. The individual requires minimal staff observation or assistance for confusion, memory impairment, or poor judgment; or
7. The individual's primary need is for behavioral management that can be provided in a community-based setting.
12VAC30-60-315. [ Ongoing Periodic ]
evaluations for individuals receiving Medicaid-funded long-term services and
supports.
A. Once an individual is [ admitted to
enrolled in home and ] community-based services, the [ home
and ] community-based services provider shall be responsible
for conducting [ ongoing periodic ] evaluations
to ensure that the individual meets, and continues to meet, the waiver program
or PACE criteria, if appropriate. These [ ongoing periodic ]
evaluations shall be conducted using the Level of Care Review tab in the
Medicaid portal. (https://www.virginiamedicaid.dmas.virginia.gov/wps/portal).
[ The home and community-based services provider shall
promptly evaluate the individual after he experiences a significant change in
his condition, as defined in 12 VAC 30-60-301. ]
B. Once an individual is admitted to a NF, the NF shall be
responsible for conducting [ ongoing periodic ]
evaluations to ensure that the individual meets, and continues to
meet, the NF criteria. For this purpose, the NF shall use the federally
required Minimum Data Set (MDS) form (see
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html).
The post-admission evaluation shall be conducted no later than 14 days after
the date of NF admission and promptly after an individual's significant change [ in
his condition ] , as defined in 12 VAC 30-60-301 [ , in
condition ] .
C. For individuals who are enrolled in [ a
an ] MCO that is responsible for providing LTSS, the MCO
shall conduct [ ongoing periodic ] evaluations
by qualified MCO staff to ensure the individual continues to meet criteria for
LTSS. [ The MCO shall promptly evaluate the individual after
he experiences a significant change in his condition, as defined in 12 VAC
30-60-301. ]
FORMS (12VAC30-60)
Certificate of Medical Necessity -- Durable Medical Equipment and Supplies, DMAS 352 (rev. 8/95).
Request for Hospice Benefits, DMAS 420 (rev. 1/99).
Medicaid Funded Long-Term Services and Supports Authorization Form, DMAS-96 (rev. 12/2015)
Individual Choice - Institutional Care or Waiver Services Form, DMAS-97 (rev. 8/2012)
Virginia Uniform Assessment Instrument [ Revised XXXXX ]
Virginia Uniform Assessment Instrument, DMAS-98 (eff. 2/2016), including:
UAI-A; UAI-B; [ Eligibility Communication
Document; ] Screening for Mental Illness, Mental
Retardation/Intellectual Disability, or Related Conditions; MI/MR Supplemental:
Level II; Medicaid Funded Long-Term Care Service Authorization Form; Individual
Choice - Institutional Care or Waiver Services Form; and [ Attachment
to Public Pay Short Form Assessment DMAS-108 Tech Waiver Adult
Referral; DMAS-109 Tech Waiver Pediatric Referral ]
Community-Based Care Level of Care Review Instrument, DMAS-99LOC (undated)
[ DMAS-108 NEED FORM NAME ]
[ DMAS-109 NEED FORM NAME ]
DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-60)
Department of Medical Assistance Services Provider Manuals (https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManuals):
Virginia Medicaid Nursing Home Manual
Virginia Medicaid Rehabilitation Manual
Virginia Medicaid Hospice Manual
Virginia Medicaid School Division Manual
Development of Special Criteria for the Purposes of
Pre-Admission Screening, Medicaid Memo, October 3, 2012, Department of Medical
Assistance Services
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR), copyright 2000, American Psychiatric Association
Patient Placement Criteria for the Treatment of Substance-Related Disorders (ASAM PPC-2R), Second Edition, copyright 2001, American Society on Addiction Medicine, Inc.