TITLE 12. HEALTH
Title of Regulation: 12VAC30-60. Standards Established and Methods Used to Assure High Quality Care (amending 12VAC30-60-303, 12VAC30-60-310; adding 12VAC30-60-301, 12VAC30-60-302, 12VAC30-60-304, 12VAC30-60-305, 12VAC30-60-306, 12VAC30-60-308, 12VAC30-60-313, 12VAC30-60-315; repealing 12VAC30-60-300, 12VAC30-60-307, 12VAC30-60-312).
Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Public Hearing Information: No public hearings are scheduled.
Public Comment Deadline: November 3, 2017.
Agency Contact: Emily McClellan, Regulatory Supervisor, Department of Medical Assistance Services, Policy Division, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-4300, FAX (804) 786-1680, or email emily.mcclellan@dmas.virginia.gov.
Basis: Section 32.1-325 of the Code of Virginia grants to the Board of Medical Assistance Services the authority to administer and amend the Plan for Medical Assistance. Section 32.1-324 of the Code of Virginia authorizes the Director of the Department of Medical Assistance Services (DMAS) to administer and amend the Plan for Medical Assistance according to the board's requirements. The Medicaid authority as established by § 1902(a) of the Social Security Act (42 USC § 1396a) provides governing authority for payments for services.
The 2016 Acts of the Assembly, Chapter 780, Item 306 PPP directs DMAS to contract out community-based screenings for children, track and monitor all requests for screenings that have not been completed within 30 days of an individual's request, establish reimbursement and tracking mechanisms, and promulgate regulations to implement these provisions.
Purpose: In responding to the legislative mandate of the General Assembly, the purpose of the planned regulatory action is to define terms and establish regulatory requirements for (i) accepting screening requests; (ii) managing the screening process; (iii) submitting findings from screenings completed to the agency's electronic preadmission screening (ePAS) system by community and hospital preadmission screening (PAS) teams and contractors performing these activities; and (iv) establishing training requirements and competency assessment standards applicable to local agency screening staff.
Substance:
Current policy. The screening policy that was in place before the emergency regulation took effect contained the requirements for Medicaid-funded long-term services supports, including home-based and community-based services (HCBS) waivers, the Program of All-Inclusive Care for the Elderly (PACE), and nursing facility services. The policy also includes the three criteria for an individual's receipt of these services: (i) functional capacity (degree of assistance an individual needs to perform activities of daily living); (ii) medical or nursing needs; and (iii) the individual's risk of nursing facility placement in the absence of home and community based services.
12VAC30-60-303 lists the specific functional criteria that are used to evaluate the extent to which each individual can perform each of the activities of daily living (ADLs), such as feeding, bathing, toileting, transferring, etc., and what type of assistance the individual needs to perform each ADL safely. These functional criteria, reflected in the Uniform Assessment Instrument (UAI) form, are not changing in this regulatory action, and the use of the UAI for this purpose remains the same. The changes that are being made to this section are editorial and technical in nature (such as substituting the acronym ADL for Activities of Daily Living and renumbering the individual items under subsection B).
Specific instructions and reporting requirements were also provided for nursing facilities once an individual had chosen and was admitted into the facility. These are also not changing.
Issues. Since the inception of the preadmission screening process in the early 1980s, the number of screenings performed in communities by local department of social services (LDSS) and local health department (LHD) teams and in hospitals by hospital staff has grown to approximately 20,000 screenings per year. In state fiscal year 2016, 350 providers performed 22,901 screenings. Of the 350 providers, 120 were local department of social services offices that do not get paid directly through fee for service claims; 117 were local health department clinics; and the rest were mainly hospitals. Payments for screenings through fee for service claims were $2,282,345 total funds, of which 75%, or $1,711,759, were federal funds. The Centers for Medicare and Medicaid Services uses a 90% federal matching rate for such screenings.
Anecdotal reports of long waits for community screenings and the corresponding delays of critical Medicaid-funded long-term services and supports (LTSS), subsequently resulted in passage of House Bill 702 (2014 Session). HB 702 required DMAS to contract with public or private entities to perform screenings in jurisdictions where the community-based preadmission screening teams have been unable to complete screenings of individuals within 30 days of such individuals' requests for a screening. No appropriation accompanied this directive.
On April 15, 2014, the Virginia Department of Health and the Department for Aging and Rehabilitative Services conducted a point-in-time manual data collection initiative from each LDSS and LHD. DMAS coordinated the data analysis. The purposes of the data collection were to (i) determine the number of community-based screenings taking longer than 30 days to complete and (ii) identify jurisdictions that were able to meet the 30-day timeframe and those unable to achieve the timeframe. DMAS' trend analysis indicated that:
1. Backlogs in community-based screenings reported by LDSS and LHDs were not always congruent across the two agencies;
2. Some reports from localities on community-based screening backlogs showed no corresponding increases in the number of screening requests over time; and
3. Some localities having significant increases in the number of community-based screening requests were able to meet the 30-day completion requirement as specified in HB 702 even with the increasing volume.
In addition to the data collection for the community-based screenings, hospitals performing screenings for inpatients (adults and children) may not be completing needed screenings prior to patient discharges. During the hospital discharge process, an inpatient is screened for the most complex care required to meet the inpatient's post-discharge needs. DMAS' data reveals that when a screening is performed by a hospital, the resulting recommendation 88% of the time is that an individual utilize nursing facility services rather than receiving supports at home.
Medicare funds up to 100 days of skilled nursing facility (SNF) or rehabilitative care, resulting frequently in discharges of individuals who still have unmet care needs subsequent to their nursing facility or rehabilitation stay. Medicare funding is not available for community-based long-term care services that are covered by Medicaid. When the individual has been admitted, without a prior screening, to either a Medicare-funded skilled nursing facility or rehabilitation facility and, upon completion of the ordered rehabilitation or exhaustion of the 100 days of Medicare benefit, is then subsequently discharged to his home, the individual must immediately request a preadmission screening from a community team, thus delaying essential LTSS. Depending on (i) the individual's capabilities; (ii) his available community support system, if any; and (iii) the community screening team's pending screening requests, such individuals may experience endangerment of their health, safety, and welfare due to delays in needed LTSS.
For both community and hospital based screenings, staff resources are limited. Therefore, efficiency in the screening process is critical to managing the growing workload. The "paper-driven" screening process has proven to be too cumbersome and slow. The form used for the screening process is the Uniform Assessment Instrument (UAI), along with other DMAS forms used for the screening process, including the DMAS-95 MI/MR/RC, DMAS-95 MI/MR/RC Supplement, DMAS-96 (Medicaid Funded LTC Service Authorization), and the DMAS-97 (Individual Choice-Institutional Care or Waiver Services). The previous absence of an automated process to assist community and hospital preadmission screening teams to complete these forms accurately and quickly and to enable tracking of requests for and completions of screenings has significantly barred efficient administration and prompt service delivery. The proposed regulation includes the use of an ePAS system to address this issue.
Before the emergency regulation went into effect, the policy was silent regarding acceptance of requests for screenings, timeframes for completing or referring requests to a contractor, and tracking mechanisms for statewide consistency in the assurance of quality services and to ensure health, safety, and welfare for individuals requesting Medicaid-funded LTSS. Also absent from that policy were definitions and requirements to standardize and regulate community-based and hospital PAS teams when accepting requests for screenings, managing those requests within the established time period, and reporting the outcomes of the screenings once individuals receive screenings.
Recommendations. The General Assembly directed DMAS to improve the preadmission screening process for individuals who will be eligible for long-term services and supports. This mandate directed DMAS to (i) develop a contract with an entity for the purpose of conducting preadmission screenings for children; (ii) track and monitor all requests for screenings and report on those screenings that are not completed within 30 days of the initial request; (iii) report on the progress of meeting these new requirements; and (iv) promulgate emergency regulations to implement these provisions. The Joint Legislative Audit and Review Commission (JLARC) reported on the Commonwealth's long-term services and supports screening at http://jlarc.virginia.gov/pdfs/reports/Rpt489.pdf.
The prior policy related to the requirements for functional eligibility (12VAC30-60-303 B) for Medicaid-funded LTSS is being retained since these standards support the eligibility process for the DMAS home and community based waiver programs (the Elderly or Disabled with Consumer Direction (EDCD) waiver, the Technology Assisted waiver, the Alzheimer's Assisted Living waiver, the Program of All-Inclusive Care for the Elderly (PACE), and nursing facility care.
This proposed regulation repeals the existing nursing facility criteria (12VAC30-60-300) in order to move the criteria to a new location within new section 12VAC30-60-303. To be clear, the functional criteria, based on the Uniform Assessment Instrument (UAI) form, are not changing in this regulatory action, and the use of the UAI for this purpose remains the same. This action simply moves the existing criteria to a new location in the regulatory chapter to improve the readability of the regulation.
The remaining policy that was in effect prior to the emergency regulations, as it appeared in the current Virginia Administrative Code, was incomplete and fragmented as the result of having been created and modified over a number of years. To remedy this, the emergency regulation additions include a Definitions section (12VAC30-60-301) and sections describing the requirement for the request for screenings (12VAC30-60-304), screenings for Medicaid-funded LTSS (12VAC30-60-305), submission of screenings to the ePAS system (12VAC30-60-306), individuals determined to not meet criteria (12VAC30-60-313), and ongoing evaluations for individuals receiving Medicaid-funded LTSS (12VAC30-60-315). These additions remain in this proposed stage regulation.
DMAS is also recommending that a training program (12VAC30-60-310) be developed to be applicable to all screening entities and their staff who will be performing screenings. The training program will provide testing that staff must pass at a standard of 80% in order for the staff to be authorized to conduct screenings. DMAS will be contracting this element via the state proposal process, and the system will be available online to avoid travel time and expenses. A training program was a specific recommendation of JLARC in its report about preadmission screening. These proposed stage regulations provide for a delayed effective date of the onset of this requirement to permit local agency staff and hospital staff time to fulfill this requirement.
Issues: Section 32.1-330 of the Code of Virginia requires that all individuals who will be eligible for community or institutional long-term services and supports as defined in the State Plan for Medical Assistance be evaluated to determine their need for Medicaid-funded nursing facility services. Also, the Code of Virginia specifically requires DMAS to utilize employees of local departments of social services and local health departments for community screenings and hospitals for inpatient screenings, respectively. While this screening structure, established in the early 1980s, worked effectively for many years, the evolution of Virginia's Medicaid service delivery system has outgrown the original design. Significant challenges have developed that require a change to the Virginia Administrative Code. Some community-based screenings have taken longer than 30 days to complete thereby creating a significant risk to individuals who have been unable to access Medicaid LTSS.
One potential issue may continue to be limited staff resources in community and hospital settings. The proposed regulations clarify requirements of community and hospital preadmission screening teams and include requirements to use the automated ePAS system to enhance work efficiency. The proposed regulations also establish DMAS use of a contractor or contractors and provide a framework for public or private entities to screen children and adults in communities where community preadmission screening teams are unable to complete screenings within 30 days of the initial request date for a screening.
With the onset of required managed care for the majority of Medicaid members, DMAS is also adding that managed care organization care coordinators will have the authority to request screenings for their members.
These strategies have been designed to ensure prompt services to citizens requesting Medicaid-funded LTSS and to protect their health, safety, and welfare.
Department of Planning and Budget's Economic Impact Analysis:
Summary of the Proposed Amendments to Regulation. Pursuant to a legislative mandate, the Department of Medical Assistance Services (DMAS) proposes to incorporate into the regulation preadmission screening policies that are currently followed. DMAS also proposes to establish a new training program for the entities that conduct preadmission screening.
Result of Analysis. The benefits likely exceed the costs for all proposed changes.
Estimated Economic Impact. The existing regulation for nursing facility criteria and preadmission screening (PAS) was first promulgated in 1994 and amended in 2002. The regulation includes the criteria for receiving Medicaid-funded community-based and nursing facility long term services and supports (LTSS). Item 301 QQQQ.1 of the 2015 Appropriation Act1 directed DMAS to promulgate emergency regulations to "improve the preadmission screening process for individuals who will be eligible for long-term care services." This proposed action follows the emergency regulation and incorporates the changes already made on a permanent basis.
Before the emergency regulation went into effect, the regulation was silent regarding acceptance of requests for screenings, timeframes for completing or referring requests to a contractor, and tracking mechanisms for statewide consistency in the assurance of quality services and to ensure health, safety, and welfare for individuals requesting Medicaid-funded LTSS. Also absent were definitions and requirements to standardize and regulate community-based and hospital PAS teams when accepting requests for screenings, managing those requests within the established time period, and reporting the outcomes of the screenings once individuals receive screenings.
According to DMAS, the proposed regulation incorporates language on those issues consistent with the practices that have already been followed based on provider service manuals and guidance. Improving the clarity of the requirements in regulation may however help standardize, enforce, and improve the processes used to determine the appropriate type and quantity of services for the recipients.
Additionally, the proposed changes include a new training requirement for screening entities and their staff performing screenings for every three years.2 The training program will provide testing that staff must pass at a standard of 80% success rate in order for them to be authorized to conduct screenings. The training is expected to take approximately eight hours to complete. DMAS will be contracting this element via the state proposal process and the system will be available online to avoid travel time and expenses. The development of the training module is expected to be accomplished by using approximately $100,000 in federal grant funds received for that purpose. The main benefit expected is more reliable and accurate eligibility determinations conducted in a timely fashion, which in turn would help eliminate unnecessary long term care expenses and make sure those who need the services get access to them as soon as possible. A training program was a specific recommendation of the Joint Legislative Audit and Review Commission in its report about pre-admission screening.3 The proposed regulation provides for a delayed effective date of the onset of this training requirement to permit local agency staff and hospital staff time to fulfill this requirement.
Businesses and Entities Affected. There are approximately 1,000 individuals working for 120 Local Departments of Social Services, 117 Local Virginia Department of Health Clinics, and 108 hospitals performing screenings. These entities performed 35,866 screenings from May 2015 to August 2016.
Localities Particularly Affected. The proposed changes do not disproportionately affect particular localities.
Projected Impact on Employment. The proposed regulation will require training estimated to take about 8 hours. Thus, the demand for labor will increase somewhat. However, the training may increase the efficiency of screening staff reducing the demand for labor to some extent. Improved accuracy of determinations may reduce quantity of services provided unnecessarily and increase the quantity of appropriately provided services affecting the demand for labor in opposite directions.
Effects on the Use and Value of Private Property. No impact on the use and value of private property is expected.
Real Estate Development Costs. No impact on real estate development costs is expected.
Small Businesses:
Definition. Pursuant to § 2.2-4007.04 of the Code of Virginia, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."
Costs and Other Effects. There are no small businesses performing preadmission screenings.
Alternative Method that Minimizes Adverse Impact. No adverse impact on small businesses is expected.
Adverse Impacts:
Businesses. Under the proposed amendments, hospitals will be required to have their staff complete the preadmission screening training.
Localities. The proposed amendments will not adversely affect localities.
Other Entities. The proposed amendments will require staff conducting screenings at Local Departments of Social Services and Local Virginia Department of Health Clinics complete training.
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1 This language is continued in the 2016 and 2017 Appropriation Acts. See Item 306 PPP.2 of the 2016 Appropriation Act and Item 306 PPP.2 of the 2017 Appropriation Act.
2 While this regulation was undergoing development, Chapter 749 of the 2017 Acts of Assembly added a statutory requirement that screeners be trained and certified.
3 See http://jlarc.virginia.gov/pdfs/reports/Rpt489.pdf
Agency's Response to Economic Impact Analysis: The agency has reviewed the economic impact analysis prepared by the Department of Planning and Budget. The agency raises no issues with this analysis.
Summary:
Item 306 PPP of Chapter 780 of the 2016 Acts of Assembly directs the Department of Medical Assistance Services (DMAS) to contract out community-based screenings for children, track and monitor all requests for screenings that have not been completed within 30 days of an individual's request, and establish reimbursement and tracking mechanisms. Emergency regulations in effect since September 1, 2016, were promulgated to implement this legislative mandate. The proposed regulations are intended to supersede emergency regulations currently in effect.
The proposed regulations add requirements for accepting, managing, and completing requests for community and hospital electronic screenings for community-based and nursing facility services preadmission screening (ePAS) system. The proposal establishes the use by DMAS of a contractor or contractors and provides a framework for public or private entities to screen children and adults in communities where community preadmission screening teams are unable to complete screenings within 30 days of the initial request date for a screening. The current requirements for functional eligibility (12VAC30-60-303 B) for long-term services and supports (LTSS) are being retained since these standards support the eligibility process for the DMAS home-based and community-based waiver programs (the Elderly or Disabled with Consumer Direction Waiver, the Technology Assisted Waiver, the Alzheimer's Assisted Living Waiver, the Program of All-Inclusive Care for the Elderly, and nursing facility care).
This proposed action repeals the existing nursing facility criteria (12VAC30-60-300) and moves the criteria to a new location within 12VAC30-60-303. The functional criteria, based on the Uniform Assessment Instrument (UAI) form, are not changing in this regulatory action, and the use of the UAI for this purpose remains the same.
Proposed amendments include adding a definitions section (12VAC30-60-301) and sections describing the requirement for the request for screenings (12VAC30-60-304), screenings for Medicaid-funded LTSS (12VAC30-60-305), submission of screenings (12VAC30-306), ePAS requirements and submissions (12VAC30-60-310), individuals determined to not meet criteria (12VAC30-60-313), and ongoing evaluations for individuals receiving Medicaid-funded LTSS (12VAC30-60-315).
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 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 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 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.
"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.
"Home and community-based services waiver" or "waiver services" means the range of community services and supports 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 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, 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.
"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.
"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.
"Nursing facility" or "NF" means any nursing home as defined in § 32.1-123 of the Code of Virginia.
"Other assessor designated by DMAS" means an employee of the local department of social services holding the occupational title of family services specialist.
"Preadmission screening" or "screening" means the process to (i) evaluate the functional, 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 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 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.
"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, the individual's representative, an adult protective services worker, child protective services worker, 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, individual's representative, adult protective services worker, child protective services worker, or managed care organization (MCO) care 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, 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 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 forms. Screening entities shall 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). 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 is made for LTSS.
2. Appropriate community-based services shall be evaluated 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.
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 risk for institutional placement.
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.
D. Pursuant to § 32.1-330 of the Code of Virginia, individuals shall be screened if they are eligible for Medicaid or are anticipated to become eligible for Medicaid reimbursement of their NF care within six months of NF placement.
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 facilty 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.
G. 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 alone is shall not be deemed sufficient to demonstrate the need for nursing facility care or placement or authorization for community-based care services. 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 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 components: (i) functional capacity (the degree of assistance an individual requires to complete ADLs) and (ii) medical or nursing needs. 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 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 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 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 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 evaluation of the person'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 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 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 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.
1. Requests for screenings shall be accepted from either an individual, the individual's representative, an adult protective service worker, 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 with the interested person who made the referral with either 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 ePAS (this shall be considered the submission date) within 30 days of the request date for 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.
2. The request for screening of a child residing in the community shall initiate from the parent, the entity having legal custody of that child, an emancipated child, 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, or representative, requests a screening.
1. As a part of the discharge planning process, the hospital team shall complete a 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, the entity having legal custody of the child, or the emancipated child makes a request of the hospital team; or
b. The individual, the individual's representative if there is one, parent, entity having legal custody, or emancipated child requests a consultation with hospital case management.
2. 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 they are eligible for Medicaid or are anticipated to become eligible for Medicaid within six months after admission to a NF.
12VAC30-60-305. Screenings in the community and hospitals for Medicaid-funded long-term services and supports.
A. Community screenings for adults.
1. 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 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 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 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 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, 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 and provide choice to the individual and his representative, if appropriate, of the feasible alternatives to placement in a NF.
5. If waiver services or PACE, where available, are declined, the reason for the declination 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 community-based services, the CBT shall also document that the individual is at risk of NF placement in the absence of 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 the individual's representative, as may be appropriate, 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 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 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 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 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 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 LTSS, the DMAS designee shall inform and provide choice to the child and his representative, if appropriate, of the feasible alternatives 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 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 community-based services, the DMAS designee shall also document that the individual is at risk of NF placement in the absence of 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, 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 LTSS as set out in 12VAC30-60-303, the DMAS designee shall notify in writing the parent, entity having legal custody of the child, or the emancipated child and representative, as may be appropriate, that 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 for Medicaid-funded LTSS shall be determined by the hospital screening team after completion of a screening of the individual's needs and available supports. The hospital screening team shall document a screening of 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 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 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 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, 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 LTSS, the hospital screening team shall inform and provide choice to the individual and his representative, if appropriate, of the feasible alternatives to placement in a NF.
5. If waiver services or PACE, where available, are declined, the reason for the declination 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 community-based services, the hospital screening team shall also document that the individual is at risk of NF placement in the absence of 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 the individual's representative, as may be appropriate, 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 ePAS:
1. DMAS-95 - MI/IDD/RC (Supplemental Assessment Process Form Level I);
2. DMAS-96 (Medicaid-Funded Long-Term Care Service Authorization Form), as appropriate;
3. DMAS-97 (Individual Choice - Institutional Care or Waiver Services); and
4. UAI (Uniform Assessment Instrument).
B. For screenings performed in the community, the screening entity shall submit to DMAS on 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 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.
12VAC30-60-310. [Reserved] Competency training and testing requirements.
By no later than December 31, 2018, each person performing screenings on behalf of a screening entity shall complete required training and competency assessments. A score of at least 80% on each module shall constitute satisfactory competency assessment results. The most current competency assessment 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 screenings shall complete the DMAS-approved training and pass the corresponding competency assessment 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. Failure to satisfy the training and competency assessment 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 individual shall be determined not to meet criteria for Medicaid-funded LTSS 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 evaluations for individuals receiving Medicaid-funded long-term services and supports.
A. Once an individual is admitted to community-based services, the community-based services provider shall be responsible for conducting ongoing evaluations to ensure that the individual meets, and continues to meet, the waiver program or PACE criteria, if appropriate. These ongoing evaluations shall be conducted using the Level of Care Review tab in the Medicaid portal. (https://www.virginiamedicaid.dmas.virginia.gov/wps/portal).
B. Once an individual is admitted to a NF, the NF shall be responsible for conducting ongoing 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 condition.
C. For individuals who are enrolled in a MCO that is responsible for providing LTSS, the MCO shall conduct ongoing evaluations by qualified MCO staff to ensure the individual continues to meet criteria for LTSS.
NOTICE: The following forms used in administering the regulation were filed by the agency. The forms are not being published; however, online users of this issue of the Virginia Register of Regulations may click on the name of a form with a hyperlink to access it. The forms are also available from the agency contact or may be viewed at the Office of the Registrar of Regulations, General Assembly Building, 2nd Floor, Richmond, Virginia 23219.
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).
Screening for Mental Illness, Mental Retardation/Individuals with Intellectual Disability, or Related Conditions, DMAS-95 MI/IDD/RC (rev. 12/2015)
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
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
Community-Based Care Level of Care Review Instrument, DMAS-99LOC (undated)
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.
Medicaid Memo, Reissuance of the Pre-Admission Screening (PAS) Provider Manual, Chapter IV, November 22, 2016, Department of Medical Assistance Services
Medicaid Special Memo, Subject: New Service Authorization Requirement for an Independent Clinical Assessment for Medicaid and FAMIS Children's Community Mental Health Rehabilitative Services, dated June 16, 2011, Department of Medical Assistance Services
Medicaid Special Memo, Subject: Changes to Children Community Mental Health Rehabilitative Services - Children's Services, July 1, 2010 & September 1, 2010, dated July 23, 2010, Department of Medical Assistance Services
Medicaid Special Memo, Subject: Changes to Community Mental Health Rehabilitative Services - Adult-Oriented Services, July 1, 2010 & September 1, 2010, dated July 23, 2010, Department of Medical Assistance Services
VA.R. Doc. No. R16-4355; Filed August 7, 2017, 8:01 a.m.