Title of Regulation: 12VAC30-130. Amount, Duration and Scope of Selected Services (amending 12VAC30-130-140 through 12VAC30-130-260).

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Effective Dates: February 16, 2022, through August 15, 2023.

Agency Contact: Emily McClellan, Regulatory Supervisor, Policy Division, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-4300, FAX (804) 786-1680, or email emily.mcclellan@dmas.virginia.gov.

Preamble:

Section 2.2-4011 B of the Code of Virginia states that agencies may adopt emergency regulations in situations in which Virginia statutory law or the appropriation act or federal law or federal regulation requires that a regulation be effective in 280 days or less from its enactment, and the regulation is not exempt under the provisions of § 2.2-4006 A 4 of the Code of Virginia.

Chapters 304 and 365 of the 2020 Acts of Assembly allow qualified nursing facility staff to complete the long-term services and supports (LTSS) screening for individuals who apply for or request LTSS and who are receiving non-Medicaid skilled nursing services in an institutional setting following discharge from an acute care hospital. The amendments align the regulation with statute and update terminology, including (i) adding information about assess appropriateness of community setting in meeting an individual's needs; (ii) requiring that a preadmission screening and resident review evaluator prioritize the physical and mental needs of an individual's severity of condition in determining placement and confirm an individual is accurately assessed for nursing facility level of care; and (iii) requiring that nursing facility placement determining data include evaluation of physical status, mental status, and function.

12VAC30-130-140. Definitions.

"Community Services Board (CSB)" or "CSB" means the local governmental agency responsible for local mental health, mental retardation intellectual disability, and substance abuse services. Boards function as service providers, client advocates, and community educators.

"Dementia" means, as a major neurocognitive disorder, for the purposes described herein in this part, having a primary diagnosis of dementia, as described in the Diagnostic and Statistical Manual of Mental Disorders, 3rd 5th edition, revised in 1987, or a nonprimary diagnosis of dementia unless the primary diagnosis is a major mental disorder as defined herein in this part.

"Diagnostic and Statistical Manual of Mental Disorders, 3rd 5th edition" or "DSM" means the 1987 2013 publication of the American Psychiatric Association classifying diagnoses of abnormal behavior for identifying and classifying mental disorders using common language and standard criteria.

"Interfacility transfer" means when an individual is transferred from one nursing facility (NF) to another nursing facility NF, with or without an intervening hospital stay. Interfacility transfers are subject to annual resident review rather than preadmission screening. In cases of transfer of a resident with MI or MR, ID, or a related condition (MR/RC) (RC) from a an NF to a hospital or to another NF, the transferring NF is responsible for ensuring that copies of the resident's most recent preadmission screening and annual resident review (PASARR) (PASRR) and resident assessment reports shall accompany the transferring resident.

"Intellectual disability" or "ID" means the individual has a disability, with onset before 18 years of age, that is characterized by significant limitations in both intellectual functioning and adaptive behavior. The American Association on Intellectual and Developmental Disabilities document "Intellectual Disability: Definition, Classification, and Systems of Support, 11th edition" contains descriptions of significant limitations in both intellectual functioning and adaptive behavior. A person with related conditions (RCs) means the individual has a severe chronic disability that meets all of the following conditions:

1. The severe chronic disability is attributable to:

a. Cerebral palsy or epilepsy; or

b. Any other condition, other than mental illness, found to be closely related to ID because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of people with intellectual disabilities and requires treatment or services similar to those required for these persons;

2. The severe chronic disability is manifested before the person reaches 22 years of age;

3. The severe chronic disability is likely to continue indefinitely; and

4. The severe chronic disability results in substantial functional limitations in three or more of the following areas of major life activity: self-care, understanding and use of language, learning, mobility, self-direction, and capacity for independent living.

"Level I screening or identification" means the process performed to identify nursing facility applicants with a condition of mental illness or mental retardation ID.

"Level II evaluation and determination" means the evaluation and determination process for nursing facility (NF) applicants who are identified as having a condition of mental illness, or mental retardation ID, or related condition (RC) as defined herein in this section. The purpose of the Level II evaluation and determination is to recommend placement of and services to nursing facility applicants with statutorily defined mental illness or mental retardation confirm the existence of MI, ID, or RC and determine whether specialized services are needed, and if specialized services are needed, whether NF admission is the least restrictive environment and appropriate setting for receiving services.

"Long-term services and supports screening team" or "LTSS screening team" means the hospital screening team, community-based team, nursing facility long-term services and supports screening team, or Department of Medical Assistance Services designee contracted to perform screenings pursuant to § 32.1-330 of the Code of Virginia.

"Mental Illness (MI) illness" or "MI" means a serious mental illness meeting all of the following requirements:

1. The individual has a major mental disorder diagnosable under, within the past year, had a serious and persistent mental disorder meeting the criteria specified within the Diagnostic and Statistical Manual of Mental Disorders, 3rd 5th edition, revised in 1987 2013 that is a schizophrenic, mood, paranoid, panic, or other severe anxiety disorder; somatoform disorder, personality disorder, other psychotic disorder, or another mental disorder that may lead to a chronic disability. The disorder is not a primary diagnosis of dementia, including Alzheimer's disease or a related disorder, or a non-primary diagnosis of dementia unless the primary diagnosis is a major mental disorder as defined here not secondary to dementia;

2. The disorder results in functional limitations in major life activities within the past three to six months that would be appropriate for the individual's developmental stage. An individual typically has at least one of the following characteristics on a continuing or intermittent basis:

a. Interpersonal functioning. The individual has serious difficulty interacting appropriately and communicating effectively with other persons, has a possible history of altercations, evictions, firing, fear of strangers, avoidance of interpersonal relationships, and social isolation;

b. Concentration, persistence, and pace. The individual has serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work-like structures, activities occurring in school or home settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these tasks; and

c. Adaptation to change. The individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests agitation, exacerbated signs and symptoms associated with the illness, or withdrawal from the situation, or requires intervention by the mental health or judicial system. 2. The condition has been determined by a qualified clinician to be acute or in partial remission, has recurrent or persistent features, and if the DSM includes a severity scale for the disorder, the severity level of the disorder is moderate to severe;

3. The treatment history indicates that the individual has experienced at least one of the following:

a. Psychiatric treatment more intensive than outpatient care more than once in the past two years (e.g., partial hospitalization or inpatient hospitalization); or

b. Within the last two years, due to the mental disorder, experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home, or in a residential treatment environment, or which resulted in intervention by housing or law enforcement officials.

"Mental Retardation (MR)" means the presence of a level of retardation (mild, moderate, severe, or profound) described in the American Association on Mental Retardation's Manual on Classification in Mental Retardation (1983) or has a related condition. A person with related conditions (RC) means the individual has a severe chronic disability that meets all of the following conditions:

1. It is attributable to cerebral palsy or epilepsy or any other condition, other than mental illness, found to be closely related to mental retardation because this condition may result in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons, and requires treatment or services similar to those required for these persons;

2. It is manifested before the person reaches age 22;

3. It is likely to continue indefinitely; and

4. It results in substantial functional limitations in three or more of the following areas of major life activity: self-care, understanding and use of language, learning, mobility, self-direction, and capacity for independent living. 3. The disorder results in functional impairment that has substantially interfered with or limited one or more major life activity, including activities of daily living; instrumental activities of daily living; or functioning in social, family, and academic or vocational contexts or would have caused functional impairment without the benefit of treatment or other support services; and

4. A qualified clinician has found that the mental illness is not a secondary characteristic of a primary diagnosis of dementia or a neurocognitive disorder due to Alzheimer's disease or related conditions.

"MI/MR "MI/ID Supplement" means the assessment form developed to meet the requirements of OBRA '87. Its purpose is to identify individuals with mental illness and mental retardation ID before their admission to a nursing facility.

"New admission" means an individual who is admitted to any nursing facility for the first time or does not qualify as a readmission. New admissions are subject to shall receive preadmission screening.

"Non-Medicaid-eligible Individuals" means persons who are not Medicaid eligible or are not expected to be Medicaid eligible within 180 days of admission to a nursing facility.

"Nursing Home Preadmission Screening Committee (NHPASC)" means a committee established for the purpose of determining whether a Medicaid-eligible individual meets nursing facility criteria.

"Qualified Mental Health Professional (QMHP) mental health professional" or "QMHP" means a clinician in the health profession who is trained and experienced in providing psychiatric or mental health services to individuals who have a psychiatric diagnosis. In the Commonwealth, authorized professionals and minimal qualifications for a QMHP are as follows:

1. Physician: a doctor of medicine or osteopathy licensed in Virginia;

2. Psychiatrist: a doctor of medicine or osteopathy, specializing in psychiatry and licensed in Virginia;

3. Psychologist: an individual with a master's degree in psychology from an accredited college or university with at least one year of clinical experience;

4. Social worker: an individual with a master's or bachelor's degree from a school of social work accredited or approved by the Council on Social Work Education with at least one year of clinical experience;

5. Registered nurse: a registered nurse licensed in the State Commonwealth of Virginia with at least one year of clinical experience; and

6. Mental health worker: an individual with professional education, training, and/or or a degree in human services or related field from an accredited college deemed equivalent to those described above in this definition and at least one year of clinical experience providing direct services to persons with a diagnosis of mental illness.

QMHPs who are certified by the Board of Counseling differ in regulatory requirements and scope of practice as indicated in 18VAC115-80. QMHPs holding a certification through the Board of Counseling are regulated by the Board of Counseling. QMHPs are clinicians or licensed professionals who perform duties within their scope of practice pursuant to their licensing or credentialing board.

"Readmission" means an individual who was readmitted to a facility from a hospital to which he or she the individual was transferred for the purpose of receiving care. Readmission includes being admitted to another nursing facility after a hospital admission. If an individual received a Level I screening or identification, and if needed, Level II evaluation and determination at the initial nursing facility admission, a new preadmission screening is not required. Readmissions are subject to annual resident review rather than preadmission screening.

"State Mental Health mental health authority or Mental Retardation Authority (MH/MRA) intellectual disability authority" or "SMHA/SIDA" means the designated representative of the Department of Mental Health, Mental Retardation and Substance Abuse Services Behavioral Health and Developmental Services who shall make determinations regarding placement of and services to nursing facility applicants who have conditions of mental illness or mental retardation intellectual disability.

12VAC30-130-150. Persons subject to nursing home preadmission screening and identification of conditions of mental illness and mental retardation, intellectual disability, or related conditions (Level I).

A. As a condition of a nursing facility's Medicaid participation, all persons, regardless of financial status, applying for admission to a Medicaid-certified nursing facility shall be screened to determine whether they have a condition of mental illness (MI) or mental retardation (MR) intellectual disability (ID) or a related condition (RC), and if so, whether they require the level of services provided by a nursing facility (NF). Nursing facilities shall ensure that applicants for admission have been screened, and those who are identified as being MI or (MR/RC), ID, or RC are not admitted until determinations have been made by the State Mental Health or Mental Retardation Authority (MH/MHA) SMHA/SIDA with respect to their placement and specialty services. NHPASCs LTSS screening teams complete the Level I process for individuals who are Medicaid eligible or expect to become Medicaid eligible within 180 days participating in the Medicaid long-term services and supports screening process and will refer for Level II evaluation and determination as needed. Nursing facilities are responsible for screening all other individuals who are seeking admission to a Medicaid-certified NF. Nursing facilities must ensure that the appropriate screenings are conducted for non-Medicaid eligible applicants prior to admitting an individual to a Medicaid-certified NF.

B. No individual, regardless of pay status, may be admitted to a nursing facility unless the Level I screening or identification has been completed, and, if it is determined that the individual has a condition of MI or (MR/RC), ID, or RC as defined herein in this part, then he or she the individual shall not be admitted until the Level II evaluation and determination has been made.

C. The Level I identification function shall provide at least, in the case of first time identifications, for the issuance of written notice to the individual or resident and his or her the individual's or resident's legal representative if the individual is suspected of having MI or (MR/RC), ID, or RC and is being referred to the MH/MRA SMHA/SIDA for Level II screening evaluation and determination. The NHPASC LTSS screening team shall send this notice to Medicaid-eligible individuals who participate in the Medicaid long-term services and supports screening process who are referred for a Level II screening evaluation and determination. The admitting NF shall send the notice to non-Medicaid all other individuals.

D. All Level I and Level II determinations shall be recorded in the individual's medical record.

E. When a preadmission screening has not been performed timely, prior to NF admission but is performed at a later date, federal financial participation (FFP) is available only for services furnished after the screening has been performed.

F. The state in which the individual is a resident (or will be at the time he or she the individual becomes eligible for Medicaid) must pay for the PASARR preadmission screening and resident review process and make the required determinations. In the case of non-Medicaid eligible applicants, the receiving NF is responsible to ensure that the appropriate screenings have been completed prior to the individual's admission.

12VAC30-130-160. Level II evaluation and determination.

A. For each resident of a NF nursing facility (NF) who has a condition of MI or MR/RC, ID, or related conditions (RC), the MH/MRA, as appropriate, SMHA/SIDA must determine whether the individual requires the level of services provided by a an NF, an inpatient psychiatric hospital for individuals under age younger than 21 years of age, an institution for mental disease (IMD) providing medical assistance to individuals age 65 and older, an intermediate care facility for the mentally retarded (ICF/MR) intellectually disabled, or specialized services for either MI, ID, or MR/RC RC.

B. When a Level II evaluation is required, a determination shall be made within an annual average of seven to nine working days of the Level I referral for screening evaluation and determination. The MH/MRA SMHA/SIDA shall convey determinations verbally to NFs Level I screeners and the individual and confirm them in writing.

C. The MH/MRA SMHA/SIDA shall notify in writing the following entities of a Level II evaluation and determination:

1. The evaluated individual and his or her the evaluated individual's legal representative;

2. The admitting or retaining NF;

3. The individual or resident's attending physician; and

4. The discharging hospital or Level I screening or identification entity.

D. Each notice described above in this section shall include the following:

1. Whether a an NF level of services is needed;

2. Whether specialized services are needed;

3. The placement options available to the individual consistent with the determination; and

4. The rights of the individual to appeal the determination.

12VAC30-130-170. Categorical determinations.

A. For each individual for whom the Level I screening or identification has resulted in the determination that the individual meets nursing facility level of care and has a condition of MI, ID, or MR/RC related conditions as defined herein in this part, a Level II evaluation and determination does not have to be completed if one of the following categorical determinations are met:

1. The individual has a terminal illness in which a physician has documented that life expectancy is less than six months; or

2. The individual has a severe illness such as coma, functioning at brain stem level, or other conditions which that result in a level of impairment so severe that the individual could not be expected to benefit from specialized services. When this category is used, documentation shall be available which that fully describes the severity of the condition.

B. These categorical determinations shall only be applied following the Level I review and only if existing data on the individual appear to be current and accurate and are sufficient to allow the evaluator readily to determine that the individual fits the category.

12VAC30-130-180. Annual resident Resident review.

A. A review and determination must be conducted for each resident of a NF nursing facility (NF) who has MI or MR/RC not less often than annually. "Annually" is defined as occurring within every fourth quarter after the previous preadmission screening or annual resident review, ID, or related conditions upon change in the resident's physical or mental condition.

B. When an annual resident review has not been performed timely, but is performed at a later date, federal financial participation (FFP) is available only for services furnished after the review has been performed If an NF has notified the SMHA/SIDA that there has been a significant change in the resident's physical or mental condition, a review must be conducted promptly.

12VAC30-130-190. Determinations and placement of individuals with MI or MR/RC mental illness, intellectual disability, or related condition.

A. If the MH/MRA SMHA/SIDA determines that a resident or applicant for admission to a NF nursing facility (NF) requires a an NF level of services, the NF may admit or retain enroll the individual. If the MH/MRA SMHA/SIDA determines that a resident or applicant for admission requires both a an NF level of services and specialized services for MI, ID, or MR/RC related conditions (RC), the NF may admit or retain the individual and the state must provide or arrange for the provision of the specialized services needed by the individual while he the individual resides in the NF.

B. If the MH/MRA SMHA/SIDA determines that an applicant for admission to a an NF does not require NF services, the applicant cannot be admitted. NF Nursing facility services are not a covered Medicaid service for that individual, and further screening is not required.

C. If the MH/MRA SMHA/SIDA determines that a resident requires neither the level of services by a an NF nor specialized services for MI, ID, or MR/RC RC, regardless of the length of stay in the facility, the state must (i) arrange for the safe and orderly discharge of the resident from the facility; and (ii) prepare and orient the resident for discharge.

D. For any resident who has continuously resided in a an NF for at least 30 months before the date of the determination, and who requires only specialized services, the state must, in consultation with the resident's family or legal representative and caregivers, (i) offer the resident the choice of remaining in the facility or of receiving services in an alternative appropriate setting; (ii) inform the resident of the institutional and noninstitutional alternatives available; (iii) clarify the effect on eligibility for Medicaid services if the resident chooses to leave the facility, including its effect on readmission to the facility or eligibility for community-based services; and (iv) regardless of the resident's choice to remain in the NF or to be discharged to a community setting, provide for, or arrange for the provision of specialized services for the MI or MR, ID, or RC.

E. For any resident who has not continuously resided in a an NF for at least 30 months before the date of the determination, the state must, in consultation with the resident's family or legal representative and caregivers (i) arrange for the safe and orderly discharge of the resident from the facility; (ii) prepare and orient the resident for discharge; and (iii) provide for, or arrange for the provision of, specialized services for the MI or MR, ID, or RC.

F. For the purposes of establishing length of stay in a an NF, the 30 months of continuous residence in the NF or longer is calculated back from the date of the first annual resident review determination which that finds that the individual is not in need of NF level of services. The 30 months of continuous residence in a an NF may include temporary absences for hospitalization and or therapeutic leave and may consist of consecutive residences in more than one NF.

G. Placement of an individual with MI, ID, or MR/RC RC in a an NF may be considered appropriate only when the individual's needs are such that he or she the individual meets the minimum standards for admission and his or her needs for treatment the individual's treatment needs do not exceed the level of services which that can be delivered in the NF to which the individual is admitted either through NF services alone or, where necessary, through NF services supplemented by specialized services provided by or arranged for by the state.

12VAC30-130-200. PASARR Preadmission screening and resident review evaluation criteria.

A. The state's PASARR preadmission screening and resident review (PASRR) program must identify all individuals who are suspected of having MI, ID, or MR/RC related conditions (RCs) as defined herein in this part. The identification function and determination that NF criteria is met is termed Level I. Level II is the function of evaluating and determining whether NF placement is appropriate to meet the individual's MH/MR/RC needs and whether nursing facility (NF) level of services and specialized services are needed.

B. Evaluations performed under PASARR PASRR and PASARR PASRR notices must be adapted to the cultural background, language, ethnic origin, and means of communication used by the individual being evaluated. PASARR Preadmission screening and resident review evaluations must involve the individual being evaluated, the individual's legal representative, if one has been designated under state law, and the individual's family if available and the individual or the legal representative agrees to family participation. When parts of a PASARR PASRR evaluation are performed by more than one evaluator, there must be interdisciplinary coordination among the evaluators.

C. All information that is necessary for determining whether it is appropriate for the individual with MI, ID, or MR/RC RC to be placed in a an NF or in another appropriate setting should be gathered throughout all applicable portions of the PASARR PASRR evaluation. The determinations relating to the need for NF level of care and specialized services are interrelated and must be based upon a comprehensive analysis of all data concerning the individual.

D. Evaluators may use relevant evaluative data, obtained prior to initiation of preadmission screening or annual resident review, if the data are considered valid and accurate and reflect the current functional status of the individual. However, in the case of individualized evaluations, the PASARR PASRR program may need to gather additional information to supplement and verify the currency and accuracy of existing data and to assess proper placement and treatment.

E. For individualized PASARR PASRR determinations, findings must be issued in the form of a written evaluative report which that (i) identifies the name and professional title of person(s) the person who performed the evaluation(s) evaluation and the date on which each portion of the evaluation was administered; (ii) provides a summary of the medical and social history, including the positive traits or developmental strengths and weaknesses or developmental needs of the evaluated individual; (iii) if NF services are recommended, identifies the specific services which that are required to meet the evaluated individual's needs; (iv) if specialized services are not recommended, identifies any specific MR/RC ID, RC, or MH mental health services which that are of a lesser intensity than specialized services that are required to meet the evaluated individual's needs; (v) if specialized services are recommended, identifies the specific MR/RC ID, RC, or MH mental health services required to meet the evaluated individual's needs; and (vi) includes the basis for the report's conclusions.

F. For categorical PASARR PASRR determinations, findings must be issued in the form of an abbreviated written evaluative report which that (i) identifies the name and professional title of the person applying the categorical determination and the data on which the application was made; (ii) explains the categorical determination(s) determination that has (have) been made; (iii) identifies, to the extent possible, based on the available data, NF services, including any mental health or specialized psychiatric rehabilitative services, that may be needed; and (iv) includes the bases for the report's conclusions.

G. For both categorical and individualized determinations, findings of the evaluation must correspond to the person's current functional status, mental health, and mental retardation ID status as documented in medical and social history records. Findings of the evaluation must be interpreted and explained to the individual and, where applicable, to a legal representative designed designated under state law by the assessment team or the MH/MRA SMHA/SIDA. The evaluation report must be sent to the individual and his the individual's legal representative, appropriate state authority in sufficient time to meet the required time frames timeframes, admitting or retaining NF, individual's attending physician, and the discharging hospital if the individual is seeking NF admission from a hospital. The determination decision must be provided to the Level I screener in a format enabling electronic entry and tracking of the results. The evaluation may be terminated at any time during the evaluation that the individual being evaluated does not have MI or MR/RC, ID, or RC or has a primary diagnosis of dementia, including Alzheimer's Disease or a related disorder, or a nonprimary diagnosis of dementia without a primary diagnosis that is a serious mental illness, and does not have a diagnosis of MR ID or a related condition.

12VAC30-130-210. Specialized services.

A. For mental illness, specialized services means the services specified by the state which that, combined with services provided by the NF nursing facility (NF), results result in the continuous and aggressive implementation of an individualized plan of care that:

1. Is developed and supervised by an interdisciplinary team, which includes a physician, qualified mental health professionals, and as appropriate, other professionals;

2. Prescribes specific therapies and activities for the treatment of persons experiencing an acute episode of serious mental illness which that necessitates supervision by trained mental health personnel;

3. Is directed toward diagnosing and reducing the resident's behavioral symptoms that may necessitate institutionalization, improving his or her the resident's level of independent functioning, and achieving a functioning level that permits reduction in the intensity of mental health services to below the level of specialized services at the earliest possible time; and

4. Prescribes inpatient psychiatric services for any individual determined to be a danger to self or others. For nursing facility NF residents who are determined to be a danger to self or others due to mental illness, the nursing facility NF must coordinate admission to an inpatient psychiatric hospital.

B. For mental retardation ID or related conditions, specialized services means the services specified by the state which that, combined with services provided by the NF or other service providers, results in treatment which that includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services, and related services that is directed toward the following;

1. The acquisition of the behaviors necessary for the individual to function with as much self-determination and independence as possible; and

2. The prevention or deceleration of regression or loss of current optimal functional status.

C. The state must provide or arrange for the provision of specialized services to all NF residents with MI or MR/RC, ID, or RC whose needs are such that continuous supervision, treatment, and training by qualified MH/MR personnel is necessary as identified by their Level I and II assessments. The NF must provide MH or MR/RC MI, ID, or RC services which that are of a lesser intensity than specialized services to all residents who need such services.

1. Services that shall be the responsibility of the nursing facility NF to provide to residents shall include, but are not limited to:

a. Physical therapy;

b. Speech-language pathology services;

c. Occupational therapy;

d. Restorative nursing;

e. Behavior management interventions that do not require ongoing consultation and monitoring by a licensed psychiatrist or psychologist;

f. Basic grooming and hygiene needs;

g. Nutritional needs, including supplements and assistance with eating;

h. Adjustment needs resulting from admission to a nursing facility an NF and ongoing psychosocial emotional support; and

i. Noncustomized durable medical equipment and supplies.

2. Specialized services for the purposes of PASARR preadmission screening and resident review shall include the following. The State Mental Health or Mental Retardation Authority SMHA/SIDA shall ensure the provision of specialized services when they are provided by a non-Medicaid-enrolled provider or when the services are not covered by Medicaid.

a. Partial hospitalization;

b. Transportation to Medicaid-covered services or specialized services necessary to treat conditions of mental illness or mental retardation ID;

c. Day health and rehabilitation;

d. Psychosocial rehabilitation;

e. Crisis intervention;

f. Customized durable medical equipment, for residents without a patient pay, that would allow the resident to participate in specialized services;

g. Behavior management interventions requiring ongoing consultation and monitoring by a licensed psychiatrist or psychologist;

h. One-to-one supervision necessary for behavior management;

i. Vision and hearing needs related to mental illness or mental retardation ID for persons over age older than 21 years of age;

j. Dental needs resulting from mental illness or mental retardation ID sequela for persons over age older than 21 years of age;

k. Habilitation;

l. Supported employment for persons with mental illness or mental retardation ID;

m. Case management services;

n. Individual psychotherapy;

o. Day treatment;

p. Individual and group counseling; and

q. Inpatient psychiatric care.

12VAC30-130-220. Placement options.

A. The placement options and required state actions resulting from PASARR preadmission screening and resident review (PASRR) are as follows:

1. Can be admitted to a NF nursing facility (NF). Any applicant for admission to a an NF who has MI or MR/RC, ID, or related conditions (RCs) and who requires the level of services provided by a an NF, regardless of whether specialized services are also needed, may be admitted to a an NF, if the placement is appropriate. If specialized services are also needed, the state is responsible for providing or arranging for the provision of the specialized services.

2. Cannot be admitted to a an NF. Any applicant for admission to a an NF who has MI or MR/RC, ID, or RC and who does not require the level of services provided by a an NF, regardless of whether specialized services are also needed, is inappropriate for NF placement and must be not be admitted.

3. Can be considered appropriate for continued placement in a an NF. Any NF resident with MI or MR/RC, ID, or RC who requires the level of services provided by a an NF, regardless of the length of his or her the resident's stay or the need for specialized services, can continue to reside in the NF, if the placement is appropriate.

4. May choose to remain in the NF even though the placement would otherwise be inappropriate. Any NF resident with MI or MR/RC, ID, or RC who does not require the level of services provided by the NF but does require specialized services and who has continuously resided in a an NF for at least 30 consecutive months before the date of determination may choose to continue to reside in the facility or to receive covered services in an alternative appropriate institutional or noninstitutional setting. Wherever the resident chooses to reside, the state must meet his or her the resident's specialized services needs. The determination notice must provide information concerning how, when, and by whom the various placement options available to the resident will be fully explained to the resident.

5. Cannot be considered appropriate for continued placement in a an NF and must be discharged (short-term residents). Any NF resident with MI or MR/RC, ID, or RC who does not require the level of services provided by a an NF but does require specialized services and who has resided in a an NF for less than 30 consecutive months must be discharged to an appropriate setting where the state must provide specialized services. The determination notice must provide information on how, when, and by whom the resident will be advised of discharge arrangements and of his/her the resident's appeal rights under both PASARR PASRR and discharge provisions.

6. Cannot be considered appropriate for continued placement in a an NF and must be discharged (short-term or long-term residents). Any NF resident with MI or MR/RC, ID, or RC who does not require the level of services provided by a an NF and does not require specialized services regardless of his or her the resident's length of stay, must be discharged. The determination notice must provide information on how, when, and by whom the resident will be advised of discharge arrangements and of his or her the resident's appeal rights under both PASARR PASRR and discharge provisions.

7. Specialized services needed in a an NF. If a determination is made to admit or allow to remain in a an NF any individual who requires specialized services, the determination must be supported by assurances that the specialized services that are needed can and will be provided or arranged for in a timely manner by the state in which the individual resides in the NF.

B. The state PASARR PASRR system shall maintain records of evaluations and determinations, regardless of whether they are performed categorically or individually, in order to support its determinations and actions and to protect the appeal rights of individuals subjected to PASARR PASRR. The state PASARR PASRR system shall establish and maintain a tracking system for all individuals with MI or MR/RC, ID, or RC in NFs to ensure that appeals and future reviews are performed.

12VAC30-130-230. Evaluating the need for NF nursing facility services and NF level of care (PASARR/NF).

A. For each applicant for admission to a NF nursing facility (NF) and each NF resident who has MI or MR/RC, ID, or RC, the evaluator must assess whether (i) the applicant's or resident's total needs are such that his the applicant's or resident's needs can be met in an appropriate community setting; (ii) the individual's total needs are such that they can be met only on an inpatient basis, which may include the option of placement in a home and community-based services waiver program, but for which the inpatient care would be required; (iii) if inpatient care is appropriate and desired, the NF is an appropriate institutional setting for meeting those needs; or (iv) if the inpatient care is appropriate and desired but the NF is not the appropriate setting for meeting the individual's needs, another setting such as an ICF/MR intermediate care facility for persons with intellectual and developmental disabilities (including small, community-based facilities), an IMD intermediate care facility providing services to individuals ages 65 or older, or a psychiatric hospital is an appropriate institutional setting for meeting those needs.

B. In determining appropriate placement, the evaluator must prioritize the physical and mental needs of the individual being evaluated, taking into account the severity of each condition.

C. For individuals for whom NF placement is considered an appropriate option by the evaluator, per the evaluation in subsections A and B of this section, the evaluator must assess what services for MI or ID the individual may need that are offered as part of standard NF services, including behavioral health services and specialized rehabilitative services as described in 42 CFR 483.30 and 42 CFR 483.65. At a minimum the data relied on to make a determination must include: (i) evaluation of physical status (for example, diagnoses, date of onset, medical history, and prognosis); (ii) evaluation of mental status (for example, diagnoses, date of onset, medical history, likelihood that the individual may be a danger to himself/herself self or others); and (iii) functional assessment (activities of daily living).

D. Based on the data compiled, the MH/MRA SMHA/SIDA must determine whether an NF level of services is needed.

12VAC30-130-240. Evaluating whether an individual with MI requires specialized services (PASARR/MI) the need for specialized services.

A. The purpose of this section is to identify the minimum data needs and process requirements for the state MHA SMHA/SIDA, which is responsible for determining whether or not the applicant or resident with MI needs a specialized services program for mental illness.

B. Minimum data collected must include:

1. A comprehensive history and physical examination of the person. If the history and physical examination are not performed by a physician, then a physician must review and concur with the conclusions. The following areas must be included (if not previously addressed): complete medical history; review of all body systems; specific evaluation of the person's neurological system in the areas of motor functioning, sensory functioning, gait, deep tendon reflexes, cranial nerves, and abnormal reflexes; and in case of abnormal findings which that are the basis for a NF nursing facility (NF) placement, additional evaluations conducted by appropriate specialists.

2. A comprehensive drug history, including current or immediate past use of medications that could mask symptoms or mimic mental illness.

3. A psychological evaluation of the person, including current living arrangements and medical and support systems.

4. A comprehensive psychiatric evaluation, including a complete psychiatric history, evaluation of intellectual functioning, memory functioning, and orientation, description of current attitudes and overt behaviors, affect, suicidal or homicidal ideation, paranoia, and degree of reality testing (presence and content of delusions) and hallucinations.

5. A functional assessment of the individual's ability to engage in activities of daily living and the level of support that would be needed to assist the individual to perform these activities while living in the community. The assessment must determine whether this level of support can be provided to the individual in an alternative community setting or whether the level of support needed is such that NF placement is required. The functional assessment must address the following areas: Self-monitoring self-monitoring of health status,; self-administering and scheduling of medical treatment, including medication compliance, or both,; and self-monitoring of nutritional status, handling money, dressing appropriately, and grooming.

C. The state may designate the mental health professionals who are qualified to perform the evaluations required, including the comprehensive drug history;, psychosocial evaluation;, comprehensive psychiatric evaluation;, and functional assessment; and to make the determination required.

D. Based on the data compiled, a qualified mental health professional, as designated by the state, must validate the diagnosis of mental illness and determine whether a program of psychiatric specialized services is needed.

12VAC30-130-250. Evaluating whether an individual with MR/RC mental illness, intellectual disability, or related conditions requires specialized services (PASARR/MR).

A. The purpose of this section is to identify the minimum data needs and process requirements for the state MRA SMHA/SIDA to determine whether or not the applicant or resident with mental retardation ID or a related condition needs a continuous specialized services program. Minimum data collected must include the individual's comprehensive history and physical examination results to identify the following information or, in the absence of data, must include information that permits a reviewer specifically to assess:

1. The individual's medical problems;

2. The level of impact these problems have on the individual's independent functioning;

3. All current medications used by the individual and the current response of the individual to any prescribed medications in the following drug groups: hypnotics, antipsychotics (neuroleptics), mood stabilizers and antidepressants, antianxiety-sedative agents, and anti-Parkinsonian agents.;

4. Self-monitoring of health status;

5. Self-administering and scheduling of medical treatments;

6. Self-monitoring of nutritional status;

7. Self-help development, such as toileting, dressing, grooming, and eating;

8. Sensorimotor development, such as ambulation, positioning, transfer skills, gross motor dexterity, visual motor perception, fine motor dexterity, eye-hand coordination, and extent to which prosthetic, orthotic, corrective or mechanical supportive devices can improve the individual's functional capacity;

9. Speech and language (communication) development, such as expressive language (verbal and nonverbal), receptive language (verbal and nonverbal), extent to which nonoral communication systems can improve the individual's function capacity, auditory functioning, and extent to which amplification devices (e.g., hearing aid) or a program of amplification can improve the individual's functional capacity;

10. Social development, such as interpersonal skills, recreation-leisure skills, and relationships with others;

11. Academic/educational Academic or educational development, including functional learning skills;

12. Independent living development, such as meal preparation, budgeting and personal finances, survival skills, mobility skills (orientation to the neighborhood, town, city), laundry, housekeeping, shopping, bed making, care of clothing, and orientation skills (for individuals with visual impairments);

13. Vocational development, including present vocational skills;

14. Affective development, such as interests, and skills involved with expressing emotions, making judgments, and making independent decisions; and

15. The presence of identifiable maladaptive or inappropriate behaviors of the individual based on systematic observation (, including, but not limited to, the frequency and intensity of identified maladaptive or inappropriate behaviors).

B. The state must ensure that a licensed psychologist identifies the intellectual functioning measurement of individuals with MR ID or a related condition. Based on the data compiled, the MRA SMHA/SIDA, using appropriate personnel as designated by the state, must validate that the individual has MR ID or is a person with a related condition and must determine whether specialized services for MR/RC ID and related conditions are needed. In making this determination, the MHA SMHA/SIDA must make a qualitative judgment on the extent to which the person's status reflects, singly and collectively, the characteristics commonly associated with the need for specialized services, including:

1. Inability to take care of most personal care needs; understand simple commands; communicate basic needs and wants; be employed at a productive wage level without systematic long term supervision or support; learn new skills without aggressive and consistent training; apply skills learned in a training situation to other environments or settings without aggressive and consistent training; demonstrate behavior appropriate to the time, situation, or place without direct supervision; and make decisions requiring informed consent without extreme difficulty;

2. Demonstration of severe maladaptive behavior(s) behavior that place the person or others in jeopardy to health and safety; and

3. Presence of other skill deficits or specialized training needs that necessitate the availability of trained MR ID personnel, 24 hours per day, to teach the person functional skills.

12VAC30-130-260. Appeals.

A. Following notification to the NF nursing facility (NF) of the Level II assessment evaluation and determination by the state MH/MRA SMHA/SIDA, the NF must inform the individual of the decision indicating the reasons for acceptance or denial and the method of appeal. Any individual, regardless of method of payment, who wishes to appeal the decision of the Level II evaluation and determination may do so by sending written notification to the Department of Medical Assistance Services (DMAS), Division of Client Appeals.

B. Decisions made by the annual resident review teams shall also be appealable to DMAS. The reviewed individual shall send written notification to DMAS, Division of Client Appeals.

C. All appeal requests must be made within 30 days of the individual's notification of the review decision.