Title of Regulation: 12VAC30-120. Waivered Services (adding 12VAC30-120-927).

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

Effective Date: December 30, 2015.

Agency Contact: Melissa Fritzman, Project Manager, Division of Long Term Care Services, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 225-4206, FAX (804) 612-0040, or email melissa.fritzman@dmas.virginia.gov.

Summary:

This regulatory action adopts a new section to establish criteria for approval of personal care service hours that exceed the maximum allowed limit of 56 hours per week. This action is required by Item 297 CCCCC of Chapter 890 of the 2011 Acts of Assembly and only affects the Elderly or Disabled with Consumer Direction Waiver.

Summary of Public Comments and Agency's Response: No public comments were received by the promulgating agency.

12VAC30-120-927. Exception criteria for personal care services.

DMAS shall apply the following criteria to individuals who request approval of personal care hours in excess of the maximum allowed 56 hours per week. [ The In order to qualify for personal care hours in excess of 56 hours per week, the ] waiver individual shall:

1. Presently have a minimum level of care of B (the waiver individual has a composite activities of daily living (ADL) score between seven and 12 and has a medical nursing need) or C (the waiver individual has a composite ADL score of nine or higher and has a skilled medical nursing need).

2. In addition to meeting the requirements set out in subdivision 1 of this [ subsection section ], the individual shall have [ at least ] one [ or more ] of the following:

a. Documentation of dependencies in all of the following activities of daily living: bathing, dressing, transferring, toileting, and eating/feeding, as defined by the current preadmission screening criteria (submitted to the service authorization contractor via DMAS-99);

b. Documentation of dependencies in both behavior and orientation as defined by the current preadmission screening criteria (submitted to the service authorization contractor via DMAS-99); or

c. Documentation from the local department of social services that the individual has an open case (as described in subdivisions c (1) and c (2) of this subdivision [ 2 ] ) with either Adult Protective Services (APS) or Child Protective Services (CPS) and is [ therefore ] in need of additional services beyond the maximum allowed 56 hours per week. Documentation can be in the form of a phone log contact or any other documentation supplied (submitted to the service authorization contractor via attestation).

(1) For APS an open case is defined as a substantiated APS case with a disposition of needs protective services and the adult accepts the needed services.

(2) For CPS an open case is defined as being open to CPS investigation if it is both founded by the investigation and the completed family assessment documents the case with moderate or high risk.