TITLE 12. HEALTH
Titles of Regulations: 12VAC30-50. Amount, Duration, and Scope of Medical and Remedial Care Services (amending 12VAC30-50-440, 12VAC30-50-490; repealing 12VAC30-50-450).
12VAC30-120. Waivered Services (repealing 12VAC30-120-700 through 12VAC30-120-777, 12VAC30-120-1000 through 12VAC30-120-1090, 12VAC30-120-1500 through 12VAC30-120-1550).
12VAC30-122. Community Waiver Services for Individuals with Developmental Disabilities (adding 12VAC30-122-10 through 12VAC30-122-570).
Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Effective Date: March 31, 2021.
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.
Summary:
This regulatory action redesigns three of the existing home and community-based waivers as follows: Individual and Family Developmental Disabilities Support Waiver (12VAC30-120-700 et seq.) is changing to the Family and Individual Supports (FIS) Waiver, Intellectual Disability Waiver (12VAC30-120-1000 et seq.) is changing to the Community Living (CL) Waiver, and the Day Support Waiver for Individuals with Mental Retardation (12VAC30-120-1500 et seq.) is changing to the Building Independence (BI) Waiver. The action repeals the existing regulations found in 12VAC30-120-700 et seq., 12VAC30-120-1000 et seq., and 12VAC30-120-1500 et seq. and promulgates a new chapter for the proposed FIS, CL, and BI Waivers in 12VAC30-122.
The action combines the target populations of individuals with intellectual disabilities and other developmental disabilities and offers new services that are designed to promote improved community integration and engagement. New services include (i) crisis support (including center-based and community-based) services, (ii) shared living supports, (iii) independent living supports, (iv) supported living residential, (v) community engagement supports, (vi) community coaching supports, (vii) community guide supports, (viii) workplace assistance services, (ix) private duty nursing, and (x) electronic home based supports.
The action modifies some existing services and repeals the prevocational service. Current services proposed for retention with modifications include (i) skilled nursing services, (ii) therapeutic consultation, (iii) personal emergency response systems, (iv) assistive technology, (v) environmental modifications, (vi) personal assistance services, (vii) companion services, (viii) respite services, (ix) group day services, (x) group home services, (xi) sponsored residential services, (xii) individual and family caregiver training, (xiii) supported living, (xiv) supported employment, (xv) transition services, and (xvi) services facilitation. For personal assistance services, companion services, and respite services, the proposed action retains the consumer-direction model of service delivery as currently permitted with no further expansion of this model to any of the other existing or new services.
Information gathered via the three-part Virginia Individual Developmental Disabilities Eligibility Survey (VIDES) and the Virginia Supplemental Questions plus financial eligibility determination are proposed to be combined with the Supports Intensity Scale® service needs assessment instrument through the person-centered planning process to develop each individual's unique individual service plan.
The action (i) establishes seven levels of supports to create the most equitable distribution of funding for core waiver services; (ii) uses common definitions of intellectual disability and developmental disability; (iii) establishes standards for a uniform waiting list and criteria for how individuals on the waiting list are provided their choice of available services; (iv) merges the FIS, CL, and BI Waivers target populations under the single definition of developmental disability and the individual eligibility sections into a single set of regulations at 12VAC30-122-30, 12VAC30-122-50, and 12VAC30-122-60; and (v) updates the provisions regarding case management.
Changes to the proposed regulation update citations, program components, and descriptions of current practices; clarify requirements, per public comment received on the proposed regulation; and make terms and requirements more consistent. Specific changes to the proposed regulation include (i) adjustments to timelines for waiver slot acceptance or decline; (ii) addition of language treating impact of overseas active duty military service on waiver status; (iii) clarifications to staff competency determination process by adding deemed competency, clarification of personnel record documentation, replacing Levels 6 or 7 with Tier 4, and timelines for competency; (iv) a change to the assessment tool used for children younger than five years of age; (v) inclusion of benefits planning services, community guide services, employment and community transportation services, and peer support services; and (vi) removal of EPDST consideration from skilled nursing services.
Summary of Public Comments and Agency's Response: A summary of comments made by the public and the agency's response may be obtained from the promulgating agency or viewed at the office of the Registrar of Regulations.
12VAC30-50-440. Case Support coordination/case management services for individuals with mental retardation intellectual disability.
A. Target Group. Medicaid eligible individuals who are mentally retarded have an intellectual disability as defined in [ state law § 37.2-100 of the Code of Virginia ].
1. An active client individual for mental retardation case intellectual disability support coordination/case management shall mean an individual a person for whom there is a plan of care an individual support plan (ISP) [ (as defined in 12VAC30-122-20) ] in effect which that requires regular direct or client-related individual-related contacts or communication or activity with the client individual, the individual's family or caregiver, service providers, significant others, and others including at least one face-to-face contact with the individual every 90-days 90 days. Billing can be submitted for an active client individual only for months in which direct or client-related individual-related contacts, activity, or communications occur, [ consistent with the ISP ].
2. The unit of service is one month. There shall be no maximum service limits for case management support coordination/case management services except case management services for as related to individuals residing in institutions or medical facilities. For these individuals, reimbursement for case management support coordination/case management shall be limited to thirty 30 days immediately preceding discharge. Case management Support coordination/case management for institutionalized individuals who reside in an institution may be billed for no more than two predischarge periods in twelve within 12 months.
B. Services will be provided in the entire State state.
C. Comparability of Services services: Services are not comparable in amount, duration, and scope. Authority of section § 1915(g)(1) of the Social Security Act (the Act) is invoked to provide services without regard to the requirements of § 1902(a)(10)(B) of the Act.
D. Definition of Services services. Mental retardation Intellectual disability support coordination/case management services to be provided include:
1. Assessment and planning services, to include developing a Consumer Service Plan (does an individual support plan (ISP) [ as defined on 12VAC30-122-20 and in accordance with the requirements of the Final Rule found at 42 CFR 441.725 ], which does not include performing medical and psychiatric assessment but does include referral for such assessment) assessment;
2. Linking the individual to services and supports specified in the consumer service plan ISP;
3. Assisting the individual directly for the purpose of locating, [ developing identifying ], or obtaining needed services and resources;
4. Coordinating services and service planning with other agencies and providers involved with the individual;
5. Enhancing community integration by contacting other entities to arrange community access and involvement, including opportunities to learn community living skills, and to use vocational, civic, and recreational services;
6. Making collateral contacts with the individual's significant others to promote implementation of the service plan ISP and community adjustment integration;
7. Following-up Following up and monitoring to assess ongoing progress and ensuring services are delivered; and
8. Education and counseling which that guides the client individual and develops a supportive relationship that promotes the service plan ISP.
E. Qualifications of providers:
1. [ Services are not comparable in amount, duration, and scope. Authority of § 1915(g)(1) of the Act is invoked to limit ] case [ support Support ] coordination/case management providers for individuals with mental retardation intellectual disability [ and ] serious/chronic [ serious or chronic mental illness shall be limited ] to the Community Services Boards community services boards [ only to enable them to provide services to ] serious/chronically [ seriously or chronically mentally ill or ] mentally retarded [ individuals with an intellectual disability without regard to the requirements of § 1902(a)(10)(B) of the Act ]. References to providers in this section shall refer to enrolled community services boards.
2. To qualify as a provider of services through enrolled with DMAS for rehabilitative mental retardation case intellectual disability support coordination/case management, the provider of the services must shall meet certain criteria. These criteria shall be:
a. The provider must shall guarantee that clients individuals have access to emergency services on a 24-hour basis;
b. The provider must shall demonstrate the ability to serve individuals in need of comprehensive services regardless of the individual's ability to pay or eligibility for Medicaid reimbursement;
c. The provider must shall have the administrative and financial management capacity to meet state and federal requirements;
d. The provider must have the ability to shall document and maintain individual case records in accordance with state and federal requirements;
[ e. The provider shall submit the individual support plan in an electronic format in the state DD home and community-based services (HCBS) waiver management system for service authorization and data management for individuals enrolled in any DD HCBS waiver. The provider shall submit evidence to Department of Medical Assistance Services (DMAS) or the Department of Behavioral Health and Developmental Services (DBHDS) in specified format of follow-up and monitoring to assess ongoing progress of the ISP, ensuring services are delivered and health and safety is maintained;
f. The provider shall participate in activities designed to safeguard participants' health and safety in accordance with approved DD HCBS waiver requirements or DBHDS licensing standards; and
g. The provider shall participate in activities designed to assure ongoing compliance by DD HCBS waiver participants' providers of service subject to the Final Rule Settings Requirements found at 42 CFR 441.301(4) and as described in the approved Statewide Transition Plan; ]
[ e. h. ] The services shall be in accordance with the Virginia Comprehensive [ State Plan for ] Mental Health, Mental Retardation and Substance Abuse Services [ Medical Assistance ]; and
[ f. i. ] The provider must be certified licensed as [ a ] mental retardation case [ an intellectual developmental ] disability support coordination/case management agency by the DMHMRSAS Department of Behavioral Health and Developmental Services.
3. Providers may bill for Medicaid mental retardation case intellectual disability support coordination/case management only when the services are provided by qualified mental retardation case managers support coordinators/case managers. The case manager must support coordinator/case manager shall possess a combination of mental retardation intellectual disability work experience [ or and ] relevant education which that indicates that the individual incumbent, at entry level, possesses the following knowledge, skills, and abilities listed in this subdivision. The incumbent must have at entry level the following knowledge, skills and abilities. These must be documented or observable in the application form or supporting documentation or in observable and documented during the interview (with appropriate supporting documentation).
a. Knowledge of:
(1) The definition, and causes of intellectual disability and program philosophy of mental retardation best practices in supporting individuals who have intellectual disability;
(2) Treatment modalities and intervention techniques, such as behavior management positive behavior supports, person-centered practices, independent living skills training, [ community inclusion/employment skills, ] supportive [ counseling guidance ], family education, crisis intervention, discharge planning, and service support coordination;
(3) Different types of assessments and their uses in program service planning;
(4) Consumers' Individuals' civil and human rights;
(5) Local community resources and service delivery systems, including support services, eligibility criteria and intake process, termination criteria and procedures, and generic community resources;
(6) Types of mental retardation intellectual disability programs and services;
(7) Effective oral, written, and interpersonal communication principles and techniques;
(8) General principles of [ record ] documentation; and
(9) The service planning process and the major components of a service plan an ISP.
b. Skills in:
(1) Interviewing;
(2) Negotiating with consumers individuals and service providers;
(3) Observing, recording and reporting and documenting an individual's behaviors;
(4) Identifying and documenting a consumer's an individual's needs for resources, services, and other assistance;
(5) Identifying services within the established service system to meet the consumer's individual's needs [ and preferences ];
(6) Coordinating the provision of services [ for the individual ] by diverse public and private providers [ , generic and natural supports ];
(7) Using information from assessments, evaluations, observation observations, and interviews to develop [ and revise as needed ] service support plans;
(8) Formulating, writing, and implementing [ individualized consumer ] service [ individual ] support plans to promote goal attainment [ and community integration ] for individuals with mental retardation intellectual disability;
(9) Using [ information from ] assessment tools [ , evaluations, observations, and interviews to develop and revise as needed individual support plans (for example to ensure the ISP is implemented appropriately, identify change in status or to determine risk of crisis/hospitalization) ]; and
(10) Identifying community resources and organizations and coordinating resources and activities.
c. Abilities to:
(1) Demonstrate a positive regard for consumers individuals and their families (e.g., treating consumers people as individuals, allowing risk taking, avoiding stereotypes of people with mental retardation intellectual disability, respecting consumers' individual and families' family privacy, and believing consumers individuals can grow [ and contribute to their communities ]);
(2) Be persistent and remain objective;
(3) Work as team member, maintaining effective inter- interagency and intra-agency working relationships;
(4) Work independently, performing position duties under general supervision;
(5) Communicate effectively, verbally and in writing; and
(6) Establish and maintain ongoing supportive relationships.
F. The State state assures that the provision of case support coordination/case management services will not restrict an individual's free choice of providers in violation of § 1902(a)(23) of the Act [ and the Final Rule at 42 CFR 441.301(c)(1)(vi) ].
1. [ Eligible recipients Enrolled individuals ] will have free choice of the [ available ] providers of case support coordination/case management services.
2. [ Eligible recipients Enrolled individuals ] will have free choice of the providers of other medical care under the plan State Plan [ for Medical Assistance ].
G. Payments for case management support coordination/case management services under the plan does State Plan [ for Medical Assistance ] shall not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.
12VAC30-50-450. Case management services for individuals with mental retardation and related conditions who are participants in the Home and Community-Based Care waivers for such individuals.
A. Target group: Medicaid eligible individuals with mental retardation and related conditions, or a child under 6 years of age who is at developmental risk, who have been determined to be eligible for Home and Community Based Care Waiver Services for persons with mental retardation and related conditions.
1. An active client for waiver case management shall mean an individual who receives at least one face-to-face contact every 90 days and monthly on-going case management interactions. There shall be no maximum service limits for case management services. Case management services may be initiated up to 3 months prior to the start of waiver services, unless the individual is institutionalized.
2. There shall be no maximum service limits for case management services except case management services for individuals residing in institutions or medical facilities. For these individuals, reimbursement for case management shall be limited to thirty days immediately preceding discharge. Case management for institutionalized individuals may be billed for no more than two predischarge periods in twelve months.
B. Services will be provided in entire State.
C. Comparability of Services. Services are not comparable in amount, duration, and scope. Authority of section 1915(g)(1) of the Act is invoked to provide services without regard to the requirements of section 1902(a)(10)(B) of the Act.
D. Definition of Services. Mental retardation case management services to be provided include:
1. Assessment and planning services, to include developing a Consumer Service Plan (does not include performing medical and psychiatric assessment but does not include referral for such assessment);
2. Linking the individual to services and supports specified in the consumer service plan;
3. Assisting the individual directly for the purpose of locating, developing or obtaining needed services and resources;
4. Coordinating services with other agencies and providers involved with the individual;
5. Enhancing community integration by contacting other entities to arrange community access and involvement, including opportunities to learn community living skills, and use vocational, civic and recreational services;
6. Making collateral contacts with the individual's significant others to promote implementation of the service plan and community adjustment; and
7. Following-up and monitoring to assess ongoing progress and ensuring services are delivered; and
8. Education and counseling which guides the client and develop a supportive relationship that promotes the service plan.
E. Qualifications of Providers:
1. Services are not comparable in amount, duration, and scope. Authority of § 1915(g)(1) of the Act is invoked to limit case management providers for individuals with mental retardation and serious/chronic mental illness to the Community Services Boards only to enable them to provide services to seriously or chronically mentally ill or mentally retarded individuals without regard to the requirements of § 1902(a)(10)(B) of the Act.
2. To qualify as a provider of services through DMAS for rehabilitative mental retardation case management, the provider of the services must meet certain criteria. These criteria shall be:
a. The provider must guarantee that clients have access to emergency services on a 24 hour basis;
b. The provider must demonstrate the ability to serve individuals in need of comprehensive services regardless of the individuals' ability to pay or eligibility for Medicaid reimbursement;
c. The provider must have the administrative and financial management capacity to meet state and federal requirements;
d. The provider must have the ability to document and maintain individual case records in accordance with state and federal requirements;
e. The services shall be in accordance with the Virginia Comprehensive State Plan for Mental Health, Mental Retardation and Substance Abuse Services; and
f. The provider must be certified as a mental retardation case management agency by the DMHMRSAS.
3. Providers may bill for Medicaid mental retardation case management only when the services are provided by qualified mental retardation case managers. The case manager must possess a combination of mental retardation work experience or relevant education which indicates that the individual possesses the following knowledge, skills, and abilities, at the entry level. These must be documented or observable in the application form or supporting documentation or in the interview (with appropriate documentation).
a. Knowledge of:
(1) The definition, causes and program philosophy of mental retardation
(2) Treatment modalities and intervention techniques, such as behavior management, independent living skills training, supportive counseling, family education, crisis intervention, discharge planning and service coordination;
(3) Different types of assessments and their uses in program planning
(4) Consumers' rights
(5) Local service delivery systems, including support services
(6) Types of mental retardation programs and services
(7) Effective oral, written and interpersonal communication principles and techniques
(8) General principles of record documentation
(9) The service planning process and the major components of a service plan
b. Skills in:
(1) Interviewing
(2) Negotiating with consumers and service providers
(3) Observing, records and reporting behaviors
(4) Identifying and documenting a consumer's needs for resources, services and other assistance
(5) Identifying services within the established service system to meet the consumer's needs
(6) Coordinating the provision of services by diverse public and private providers
(7) Analyzing and planning for the service needs of mentally retarded persons
(8) Formulating, writing and implementing individualized consumer service plans to promote goal attainment for individuals with mental retardation
(9) Using assessment tools.
c. Abilities to:
(1) Demonstrate a positive regard for consumers and their families (e.g., treating consumers as individuals, allowing risk taking, avoiding stereotypes of mentally retarded people, respecting consumers' and families' privacy, believing consumers can grow)
(2) Be persistent and remain objective
(3) Work as team member, maintaining effective inter- and intra-agency working relationships
(4) Work independently, performing positive duties under general supervision
(5) Communicate effectively, verbally and in writing
(6) Establish and maintain ongoing supportive relationships.
F. The State assures that the provision of case management services will not restrict an individual's free choice of providers in violation of § 1902(a)(23) of the Act.
1. Eligible recipients will have free choice of the providers of case management services.
2. Eligible recipients will have free choice of the providers of other medical care under the plan.
G. Payment for case management services under the plan shall not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.
12VAC30-50-490. Case Support coordination/case management for individuals with developmental disabilities [ , including autism ].
A. Target group. Medicaid-eligible individuals with developmental disability [ (other than intellectual disability) ] or related conditions [ who are six years of age and older and as defined in § 37.2-100 of the Code of Virginia ] who are on the waiting list or are receiving services under one of the Individual and Family Developmental Disabilities Support (IFDDS) Waiver Developmental Disabilities (DD) Waivers.
1. [ When an individual applies for the DD Waivers and is found to meet the criteria as defined in 12VAC30-122-50, but there is no available slot, the individual will be placed on a waitlist until a slot is available. Individuals on the waitlist shall not receive developmental disability support coordination/case management services unless a special service need (as defined in subdivision 4 of this subsection) is identified, in which case an ISP shall be developed to address the special service need. Support coordinators/case managers shall make face-to-face contact with the individual at least every 90 calendar days to monitor the special service need, and documentation is required to support such contact. The support coordinator/case manager shall assure the ISP addresses the current special service needs of the individual and shall coordinate with the Department of Medical Assistance Services designee to assure actual enrollment into the waiver upon slot availability.
2. ] An active client individual for case [ developmental disability ] support coordination/case management shall mean an individual a person for whom there is a plan of care an individual support plan (ISP), as defined in 12VAC30-122-20, that requires regular direct or client-related individual-related contacts or communication or activity with the client individual, family the individual's family/caregiver, service providers, and significant others and others including at least one face-to-face contact every 90 calendar days. Billing can be submitted for an active client individual only for months in which direct or client-related individual-related contacts, activity, or communications occur, consistent with the [ activities goals or outcomes ] in the individual's ISP. Face-to-face contact between the support coordinator/case manager [ and the individual ] shall occur at least every [ three months 90 calendar days ] in which there is an activity submitted for billing.
[ 2. When an individual applies for the ] IFDDS Waiver [ DD Waivers and is found to meet the criteria as defined in 12VAC30-122-50, but ] there is no available funding (slots) slot, he will be placed on a waitlist until ] funding [ a slot is available. ] The "Initial Waitlist Plan of Care" is completed with the case manager and identifies the services anticipated once a slot is available. Individuals on the waitlist do not have routine case management services unless there is a documented special service need in the plan of care. Case managers may Individuals on the waitlist shall not receive developmental disability support coordination/case management services unless a special service need (as defined in subdivision 4 of this subsection) is identified, in which case an ISP shall be developed to address the special service need. Support coordinators/case managers shall make face-to-face contact with the individual at least every 90 calendar days to monitor the special service need, and documentation is required to support such contact. The ] case manager will [ support coordinator/case manager shall assure the ] plan of care [ ISP addresses the current special service needs of the individual and ] will [ shall coordinate with ] DMAS [ the Department of Medical Assistance Services designee to assure actual enrollment into the waiver upon slot availability. ]
3. The unit of service is one month. There shall be no maximum service limits for case support coordination/case management services except case management services for as related to individuals residing in [ medical ] institutions or medical facilities. For these individuals, reimbursement for case support coordination/case management for institutionalized individuals services [ shall be limited to 90 days immediately preceding discharge from those settings. Support coordination/case management for individuals in a medical institution or facility ] may be billed for no more than two [ months 90-day periods ] in a 12-month cycle period.
4. The unit of service is one month. There shall be no maximum service limits for case management services except case management services for individuals residing in institutions or medical facilities. For these individuals, reimbursement for case management for institutionalized individuals may be billed for no more than two months in a 12-month cycle. A special service need is one that requires linkage to and temporary monitoring of those supports and services identified in the ISP to address an individual's mental health, behavioral, and medical needs or provide assistance related to an acute need that coincides with the allowable activities noted in subsection D of this section. If an activity related to the special service need is provided in a given month, then the support coordinator/case manager would be eligible for reimbursement. Once the special service need is addressed related to the specific activity identified, billing for the service shall not continue until a special service need presents again.
B. Services will be provided in the entire state.
C. Comparability of services. Services are not comparable in amount, duration, and scope. Authority of § 1915(g)(1) of the Social Security Act (Act) is invoked to provide services without regard to the requirements of § 1902(a)(10)(B) of the Act and to limit support coordination/case management providers to the community services boards or behavioral health authorities (CSBs or BHAs). CSBs or BHAs [ may shall ] contract with private support coordinators/case managers for this service [ in accordance with subdivision F 1 of this section ].
D. Definition of services. Case Support coordination/case management services will be provided for Medicaid-eligible individuals with developmental disability or related conditions who are on the [ DD Waivers ] waiting list for or participants enrolled in one of the home and community-based care IFDDS Waiver services DD Waivers. Case Support coordination/case management services to that may be provided include:
1. Assessment and planning services, to include developing a consumer service plan (does an ISP [ as defined on 12VAC30-122-20 and in accordance with the requirements of the Final Rule found at 42 CFR 441.725 ], which does not include performing medical and psychiatric assessment but does include referral for such assessments) assessment;
2. Linking the individual to services and supports specified in the consumer service plan ISP;
3. Assisting the individual directly for the purpose of locating, developing, or obtaining needed services and resources;
4. Coordinating services and service planning with other agencies and providers involved with the individual;
5. Enhancing community integration by contacting other entities to arrange community access and involvement, including opportunities to learn community living skills and to use vocational, civic, and recreational services;
6. Making collateral contacts with the individual's significant others to promote implementation of the service plan ISP and community adjustment integration;
7. Following up and monitoring to assess ongoing progress and ensure services are delivered [ as outlined in the ISP and addressing any change of status; and ];
8. [ 7. ] Education and [ counseling that guides guidance that supports ] the individual and develops a supportive relationship that promotes the service plan ISP [ ; and ].
[ 9. 8. Benefits counseling. ]
E. Qualifications of providers. In addition to meeting the general conditions and requirements for home and community-based care participating providers as specified in 12VAC30-120-730 and 12VAC30-120-740, specific provider qualifications are:
1. To qualify as a provider of services through DMAS for IFDDS Waiver case management, the service provider must meet these criteria:
a. Have the administrative and financial management capacity to meet state and federal requirements;
b. Have the ability to document and maintain recipient case records in accordance with state and federal requirements; and
c. Be enrolled as an IFDDS case management agency by DMAS.
2. Providers may bill for Medicaid case management only when the services are provided by qualified case managers. The case manager must possess a combination of developmental disability work experience or relevant education, which indicates that the individual possesses the following knowledge, skills, and abilities, at the entry level. These must be documented or observable in the application form or supporting documentation or in the interview (with appropriate documentation).
1. CSBs or BHAs shall have current, signed provider agreements with the Department of Medical Assistance Services (DMAS) and shall directly bill DMAS for reimbursement. CSBs or BHAs [ may shall ] contract with other entities to provide support coordination/case management [ in accordance with subdivision F 1 of this section ].
2. Support coordinators/case managers shall not be (i) the direct care staff person, [ as defined in 12VAC30-122-20 ], (ii) the immediate supervisor of the direct care staff person, (iii) otherwise related by business or organization to the direct care staff person, or (iv) an immediate family member of the direct care staff person.
3. Support coordination/case management services shall not be provided to the individual by (i) parents, guardians, spouses, or any family living with the individual or (ii) parents, guardians, spouses, or any family employed by an organization that provides support coordination/case management for the individual except in cases where the family member was employed by the case management entity prior to implementation of this chapter.
4. Providers of developmental disability support coordination/case management services shall meet the following criteria:
a. The provider shall guarantee that individuals have access to emergency services on a 24-hour basis pursuant to § 37.2-500 of the Code of Virginia;
b. The provider shall demonstrate the ability to serve individuals in need of comprehensive services regardless of the individual's ability to pay or eligibility for Medicaid;
c. The provider shall have the administrative and financial management capacity to meet state and federal requirements;
d. The provider shall document and maintain individual case records in accordance with state and federal requirements; and
e. [ The provider shall submit the individual support plan in an electronic format in the state DD home and community-based services (HCBS) waiver management system for service authorization and data management for individuals enrolled in any DD HCBS waiver. The provider shall submit evidence of follow-up and monitoring to assess ongoing progress of the ISP, ensuring services are delivered and health and safety is maintained;
f. The provider shall participate in activities designed to safeguard participants' health and safety in accordance with approved DD HCBS waiver requirements or DBHDS licensing standards;
g. The provider shall participate in activities designed to assure ongoing compliance by DD HCBS waiver participants' providers of service subject to the Final Rule Settings Requirements found at 42 CFS 441.301(4) and as described in the approved Statewide Transition Plan; and
h. ] The provider shall be licensed as a support coordination/case management entity.
5. The provider shall ensure that support coordinators/case managers who provide developmental disability support coordination/case management services and were hired after September 1, 2016, shall possess a minimum of a bachelor's degree in a human services field or be a registered nurse. Support coordinators/case managers hired before September 1, 2016, who do not possess a minimum of a bachelor's degree in a human services field [ or are not a registered nurse ] may continue to provide support coordination/case management if they are employed by or contracting with an entity that has [ or had ] a Medicaid provider participation agreement to provide developmental disability support coordination/case management prior to February 1, 2005, and the support coordinator/case manager has maintained employment with the provider without interruption and that is documented in the personnel record.
6. In addition to the requirements in subdivision 5 of this subsection, the support coordinator/case manager shall possess developmental disability work experience or relevant education that indicates that at entry level he possesses the following knowledge, skills, and abilities that shall be documented in the employment application form or supporting documentation or during the job interview:
a. Knowledge of:
(1) The definition, and causes, of developmental disability and program philosophy of best practices in supporting individuals who have developmental disabilities;
(2) Treatment modalities and intervention techniques, such as behavior management positive behavioral supports, person-centered practices, independent living skills, training, [ community inclusion/employment training, ] supportive [ counseling guidance ], family education, crisis intervention, discharge planning, and service coordination;
(3) Different types of assessments and their uses in program planning determining the specific needs of the individual with respect to his ISP;
(4) Individuals' human and civil rights;
(5) Local service delivery systems, including support services;
(6) Types of developmental disability programs and services [ Programs Types of programs ] and services that support individuals with developmental disabilities;
(7) Effective oral, written, and interpersonal communication principles and techniques;
(8) General principles of [ record ] documentation; and
(9) The service planning process and the major components of a service plan the ISP.
b. Skills in:
(1) Interviewing;
(2) Negotiating with individuals and service providers;
(3) Observing, recording, and reporting and documenting an individual's behaviors;
(4) Identifying and documenting an individual's needs for resources, services, and other assistance;
(5) Identifying services within the established service system to meet the individual's needs [ and preferences ];
(6) Coordinating the provision of services by diverse public and private providers [ and generic and natural supports ];
(7) Analyzing and planning for the service needs of developmentally disabled persons individuals with developmental disability;
(8) Formulating, writing, and implementing individual-specific service support plans to promote goal attainment for recipients with developmental disabilities designed to facilitate attainment of the individual's unique goals for a meaningful, quality life; and
(9) Using [ assessment tools information from assessments, evaluations, observations, and interviews to develop and revise as needed individual support plans tools (e.g., to ensure the ISP is implemented appropriately, identify change in status, or to determine risk of crisis/hospitalization). ]
c. Abilities to:
(1) Demonstrate a positive regard for individuals and their families (e.g., allowing risk taking, avoiding stereotypes of developmentally disabled people with developmental disabilities, respecting individuals' individual and families' family privacy, believing individuals can grow [ and contribute to their community ]);
(2) Be persistent and remain objective;
(3) Work as a team member, maintaining effective inter- interagency and intra-agency working relationships;
(4) Work independently, performing positive position duties under general supervision;
(5) Communicate effectively, orally and in writing; and
(6) Establish and maintain ongoing supportive relationships.
3. In addition, case managers who enroll with DMAS to provide case management services after (insert the effective date of these regulations) must possess a minimum of an undergraduate degree in a human services field. Providers who had a Medicaid participation agreement to provide case management prior to February 1, 2005, and who maintain that agreement without interruption may continue to provide case management using the KSA requirements effective prior to February 1, 2005.
4. Case managers who are employed by an organization must receive supervision within the same organization. Case managers who are self-employed must obtain one hour of documented supervision every three months when the case manager has active cases. The individual who provides the supervision to the case manager must have a master's level degree in a human services field and/or have five years of satisfactory experience in the field working with individuals with related conditions as defined in 42 CFR 435.1009. A case management provider cannot supervise another case management provider.
5. Case managers must complete eight hours of training annually in one or a combination of the areas described in the knowledge, skills and abilities (KSA) subdivision. Case managers must have documentation to demonstrate training is completed. The documentation must be maintained by the case manager for the purposes of utilization review.
6. Parents, spouses, or any person living with the individual may not provide direct case management services for their child, spouse or the individual with whom they live or be employed by a company that provides case management for their child, spouse, or the individual with whom they live.
7. A case manager may provide services facilitation services. In these cases, the case manager must meet all the case management provider requirements as well as the service facilitation provider requirements. Individuals and their family/caregivers, as appropriate, have the right to choose whether the case manager may provide services facilitation or to have a separate services facilitator and this choice must be clearly documented in the individual's record. If case managers are not services facilitation providers, the case manager must assist the individual and his family/caregiver, as appropriate, to locate an available services facilitator.
8. If the case manager is not serving as the individual's services facilitator, the case manager may conduct the assessments and reassessment for CD services if the individual or his family/caregiver, as appropriate, chooses. The individual's choice must be clearly documented in the case management record along with which provider is responsible for conducting the assessments and reassessments required for CD services.
7. Support coordinators/case managers shall receive supervision within the employing organization. The supervisor of the support coordinator/case manager shall have either:
a. A master's degree in a human services field and one year of required documented experience working with individuals who have developmental disabilities as defined in § 37.2-100 of the Code of Virginia;
b. A registered nurse license in the Commonwealth, or hold a multistate licensure privilege and one year of documented experience working with individuals who have developmental disabilities as defined in § 37.2-100 of the Code of Virginia;
c. A bachelor's degree and two years of experience working with individuals who have developmental disabilities as defined in § 37.2-100 of the Code of Virginia;
d. A high school diploma or GED and five years of paid experience in developing, conducting, and approving assessments and ISPs as well as working with individuals who have developmental disabilities as defined in § 37.2-100 of the Code of Virginia;
e. A [ doctor of medicine license or doctor of osteopathy ] license [ to practice medicine or osteopathic medicine ] in the Commonwealth and one year of required documented experience working with individuals who have developmental disabilities as defined in § 37.2-100 of the Code of Virginia; or
f. Requirements as set out in the Department of Behavioral Health and Developmental Disabilities licensing regulations (12VAC35-105-1250).
8. Support coordinators/case managers shall obtain at least one hour of documented supervision at least every [ three months 90 calendar days ].
9. A support coordinator/case manager shall complete a minimum of eight hours of training annually in one or more of a combination of areas described in the knowledge, skills, and abilities in subdivision 6 of this subsection and shall provide documentation to his supervisor that demonstrates that training is completed. The documentation shall be maintained by the supervisor of the support coordinator/case manager in the employee's personnel file for the purposes of utilization review. This documentation shall be provided to the Department of Medical Assistance Services and the Department of Behavioral Health and Developmental Services upon request.
F. The state assures that the provision of case management support coordination/case management services will not restrict an individual's free choice of providers in violation of § 1902(a)(23) of the Act [ and the Final Rule at 42 CFR 441.301(c)(1)(vi) ].
1. Eligible recipients will have free choice of the providers of case management services. To provide choice to individuals who are enrolled in the Developmental Disabilities (DD) Waivers (Building Independence (BI), Community Living (CL), and Family and Individual Supports (FIS)), CSBs or BHAs [ may shall ] contract with private support coordination/case management entities to provide developmental disabilities support coordination/case management services. If there are no qualified providers in that CSB's or BHA's catchment area, then the CSB or BHA shall provide the support coordination/case management services. The CSBs or BHAs shall be the only licensed entities permitted to be reimbursed for developmental disabilities or intellectual disability support coordination/case management services. For those individuals who receive developmental disabilities support coordination/case management services:
a. The CSB or BHA that serves the individual shall be the responsible provider of support coordination/case management. This CSB or BHA shall be the provider responsible for submitting claims to the Department of Medical Assistance Services (DMAS) for reimbursement.
b. The CSB shall inform the individual that the individual has a choice with respect to the support coordination/case management services that he receives. The individual shall be informed that he can choose from among these options:
(1) The individual may have his choice of support coordinator/case manager employed by the CSB or BHA.
(2) The individual may have his choice of another CSB or BHA with which the responsible CSB or BHA provider has a memorandum of agreement if the individual or family decides [ that no choice not to choose ] is desired in the responsible CSB or BHA provider.
(3) The individual may have a choice of a designated private provider with whom the responsible CSB or BHA provider has a contract for support coordination/case management if the individual or family decides not to choose the responsible CSB or BHA provider or another CSB or BHA when there is a memorandum of agreement.
c. At any time, the individual or family may request to change their support coordinator/case manager.
2. Eligible recipients individuals will have free choice of the providers of other medical care under the plan State Plan [ for Medical Assistance ].
[ 3. When the required support coordination/case management services are contracted out to a private entity, the responsible CSB or BHA provider shall remain the Medicaid enrolled provider for the purpose of submitting claims to DMAS for reimbursement. Only the responsible CSB or BHA provider shall be permitted to submit claims to DMAS for reimbursement of support coordination/case management services. ]
G. Payment for case management support coordination/case management services under the plan does State Plan shall not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.
EDITOR'S NOTE: Parts VIII, Individual and Family Developmental Disabilities Support Waiver, consisting of 12VAC30-120-700 through 12VAC30-120-777; Part X, Intellectual Disability Waiver, consisting of 12VAC30-1201000 through 12VAC30-120-1090; and Part XV, consisting of 12VAC30-120-1500 through 12VAC30-120-1550 are being repealed in their entirety in this final action and are not set out below. The full text of the repealed provisions of these Parts was published at the proposed stage in 35:12 VA.R. 1479-1569 February 4, 2019.
Chapter 122
Community Waiver Services for Individuals with Developmental Disabilities
12VAC30-122-10. Purpose; legal authority; covered services; aggregate cost effectiveness; required individual and provider enrollment; individual costs.
1. Supports individuals with developmental disabilities to live integrated and engaged lives in their communities;
2. Standardizes and simplifies access to services;
3. Sets out and defines services that promote community integration and engagement; [ and ]
4. Improves provider capacity and quality to render covered services; [ and
5. Facilitates meeting the Commonwealth's commitments under the community integration mandate of the Americans with Disabilities Act (42 USC § 12101 et seq.), the Supreme Court's decision in Olmstead v. L.C. (527 U.S. 581 (1999)), and the 2012 Settlement Agreement in United States of America v. Commonwealth of Virginia. ]
B. Legal authority.
1. Selected home and community-based waiver services shall be available through § 1915(c) waivers of the Social Security Act (42 USC § 1396n). The waivers shall be named (i) Family and Individual Supports (FIS), (ii) Community Living (CL), and (iii) Building Independence (BI) and are collectively referred to as the Developmental Disabilities (DD) Waivers. These waiver services shall be required, appropriate, and medically necessary to maintain an individual in the community instead of placement in an institution.
2. The Department of Medical Assistance Services (DMAS), the single state agency pursuant to 42 CFR 431.10 responsible for administrative authority over service authorizations, delegates the processing of service authorizations and daily operations to the Department of Behavioral Health and Developmental Services in accordance with the interagency Memorandum of Understanding. DMAS shall be the single state agency authority pursuant to 42 CFR 431.10 for payment of claims for the services covered in the DD Waivers and for obtaining federal financial participation from the Centers for Medicare and Medicaid Services.
C. Covered services. The services covered in the Developmental Disabilities Waivers shall be:
1. Assistive technology service (12VAC30-122-270;
2. Benefits planning service (12VAC30-122-280 [ - reserved ]);
3. Center-based crisis support service (12VAC30-122-290);
4. Community-based crisis support service (12VAC30-122-300);
5. Community coaching service (12VAC30-122-310);
6. Community [ guide engagement ] service (12VAC30-122-320 [ - reserved ]);
7. Community [ engagement guide ] service (12VAC30-122-330 [ - reserved) ]);
8. Companion service (12VAC30-122-340);
9. Crisis support service (12VAC30-122-350);
10. Electronic home-based support service (12VAC30-122-360);
11. Environmental modification service (12VAC30-122-370);
12. Group day service (12VAC30-122-380);
13. Group home residential service (12VAC30-122-390);
14. Group and individual supported employment service (12VAC30-122-400);
15. In-home support service (12VAC30-122-410);
16. Independent living support service (12VAC30-122-420);
17. Individual and family/caregiver training service (12VAC30-122-430);
18. [ Nonmedical transportation service Employment and Community Transportation ] (12VAC30-122-440 [ - reserved ]);
19. Peer support service (12VAC30-122-450 [ - reserved ]);
20. Personal assistance service (12VAC30-122-460);
21. Personal emergency response system service (12VAC30-122-470);
22. Private duty nursing service (12VAC30-122-480);
23. Respite service (12VAC30-122-490);
24. Services facilitation service (12VAC30-122-500);
25. Shared living support service (12VAC30-122-510);
26. Skilled nursing service (12VAC30-122-520);
27. Sponsored residential support service (12VAC30-122-530);
28. Supported living residential service (12VAC30-122-540);
29. Therapeutic consultation service (12VAC30-122-550);
30. Transition service (12VAC30-122-560); and
31. Workplace assistance service (12VAC30-122-570).
D. Aggregate cost effectiveness. Federal waiver requirements, as established in § 1915 of the Social Security Act and 42 CFR 430.25, provide that the average per capita fiscal year expenditures in the aggregate under the DD Waivers shall not exceed the average per capita expenditures in the aggregate for the level of care provided in ICFs/IID, as defined in 42 CFR 435.1010 and 42 CFR 483.440, under the State Plan for Medical Assistance that would have been provided had the DD Waivers not been granted.
E. No waiver services shall be reimbursed until after both the provider enrollment process and the individual eligibility determination process have been completed [ and the individual is enrolled in a waiver ]. A determination of individual eligibility for waiver services shall not determine claim reimbursement. [ Individuals shall be enrolled to receive services in order for provider reimbursement to occur. To be considered for reimbursement, a provider's claims must be for services rendered to individuals enrolled to receive waiver services. ]
1. No back-dated payments shall be made for services that were rendered before the completion of the provider enrollment and the individual [ eligibility determination waiver enrollment ] processes.
2. Individuals who are enrolled in these waivers who choose to employ their own companions or assistants prior to the completion of the provider enrollment process shall be responsible for reimbursing such costs themselves.
3. No back dating of provider enrollment requirements shall be permitted [ in order for ] DMAS [ to will not ] reimburse for prematurely incurred costs.
F. With the exception of costs specified in subsection E of this section that waiver individuals may elect to incur, no costs for evaluations or assessments that may be required by either DMAS or DBHDS shall be borne by the individual.
12VAC30-122-20. Definitions.
The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:
"AAIDD" means the American Association on Intellectual and Developmental Disabilities.
"Activities of daily living" or "ADLs" means personal care tasks, for example, bathing, dressing, using a toilet, 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.
"Agency-directed model" means a model of service delivery where an agency is responsible for providing direct support staff, for maintaining individuals' records, and for scheduling the dates and times of the direct support staff's presence in an individual's home and in community.
"Appeal" means the process used to challenge actions regarding services, benefits, and reimbursement provided by Medicaid pursuant to 12VAC30-110 and 12VAC30-20-500 through 12VAC30-20-560.
"Assistive technology" or "AT" means specialized medical equipment and supplies, including those devices, controls, or appliances specified in the individual support plan but not available under the State Plan for Medical Assistance that [ (i) ] enable individuals to increase their abilities to perform ADLs [ or to; (ii) enable individuals to ] perceive, control, or communicate with [ the their ] environment [ in which they live; (iii) actively participate in other waiver services that are part of their plan for supports; ] or [ (iv) that ] are necessary to the proper functioning of the specialized equipment.
[ "Back-up plan" means provision for alternative arrangements for the delivery of services that are critical to participant well-being in the event that the provider responsible for furnishing the services fails or is unable to deliver them. ]
"Barrier crime" means those crimes listed in [ § 19.2-392.02 of the Code of Virginia and as they apply to ] §§ 32.1-162.9:1, 37.2-314, 37.2-416, 37.2-506, 37.2-607, and 63.2-1719 of the Code of Virginia.
"Behavioral health authority" or "BHA" means the same as defined in § [ 37.2-600 37.2-100 ] of the Code of Virginia.
[ "Benefits planning" means an individualized analysis and consultation service that assists recipients of a DD waiver and social security (SSI, SSDI, SSI/SSDI) to understand their personal benefits and explore their options regarding working, how to begin employment, and the impact employment will have on their state and federal benefits. ]
"BI" means the Building Independence Waiver as further described in 12VAC30-122-240.
"Center-based crisis support services" means [ crisis prevention and stabilization in a crisis therapeutic home using planned and emergency admissions. The services are designed for those individuals who need ongoing crisis supports. crisis support services provided in a crisis therapeutic home. ]
"Centers for Medicare and Medicaid Services" or "CMS" means the unit of the U.S. Department of Health and Human Services that administers and funds the Medicare and Medicaid programs.
"Challenging behavior" means behaviors of such intensity, frequency, and duration that the physical safety of the individual or others is placed in serious jeopardy or the behavior limits access to the community. Challenging behavior may include withdrawal, self-injury, injury to others, aggression, or self-stimulation.
"CL" means the Community Living Waiver as described in 12VAC30-122-250.
"Community-based crisis support services" means [ crisis support ] services [ for individuals who are experiencing crisis events that put them at risk for homelessness, incarceration, hospitalization, or that create a danger to themselves or others and includes ongoing supports provided ] to individuals in their homes and in community settings.
"Community coaching" means a service designed for individuals who require one-to-one support in a variety of community settings in order to develop specific skills to address barriers that prevent that individual from participating in community engagement services.
"Community engagement" means, for the purpose of building relationships and natural supports, services that support and foster individuals' abilities to acquire, retain, or improve skills necessary to build positive social behavior, interpersonal competence, greater independence, employability, and personal choice necessary to access typical activities and benefits of community life equal to those available to the general population. Community engagement services shall be provided in groups no larger than [ one staff person to ] three individuals [ with a minimum of one DSP ].
[ "Community Guide" means direct assistance to promote individuals' self-determination through brokering specific community resources that lead to connection to and independent participation in integrated, independent housing, or community activities so as to avoid isolation. ]
"Community services board" or "CSB" means the same as defined in § 37.2-100 of the Code of Virginia.
"Companion" means a person who provides companion services for compensation by DMAS.
"Companion services" means nonmedical care, support, and socialization provided to an adult individual age 18 years and older in accordance with a therapeutic goal in the individual support plan. Companion services are not purely recreational in nature [ but and ] shall not provide routine support with ADLs.
"Consumer direction" means a model of service delivery for which the individual or the individual's employer of record, as appropriate, shall be responsible for hiring, training, supervising, and firing of the person who provides the direct support or specific services covered by DMAS and whose wages are paid by DMAS through its fiscal agent.
"Crisis support services" means intensive supports by trained and, where applicable, licensed staff in crisis prevention, crisis intervention, and crisis stabilization for an individual who is experiencing an episodic behavioral or psychiatric event that has the potential to jeopardize his current community living situation.
"Customized rate" means a reimbursement rate [ that may be ] available to group home residential, sponsored residential, supported living residential, group day, community coaching, and in-home support service providers that exceeds the normal rate applicable to the individual receiving these specific services.
"DARS" means the Department for Aging and Rehabilitative Services.
"DBHDS" means the Department of Behavioral Health and Developmental Services.
"DBHDS staff" means persons employed by or contracted with DBHDS.
[ "Develomental "Developmental ] Disability Waivers" or "DD Waivers" means the waiver program established in [ 12VAC30-122 this chapter ] and consisting of the FIS, CL, and BI waivers.
"Developmental disability" means the same as defined in § 37.2-100 of the Code of Virginia.
"Direct support professional," "direct care staff," or "DSP" means staff members identified by the provider as having the primary role of assisting an individual on a day-to-day basis with routine personal care needs, social support, and physical assistance in a wide range of daily living activities so that the individual can lead a self-directed life in his own community. This term shall exclude consumer-directed staff and services facilitation providers.
"DMAS" means the Department of Medical Assistance Services.
"DMAS staff" means persons employed by or contracted with DMAS.
"Electronic home-based support" or "EHBS" means goods and services based on current technology, such as Smart Home©, and includes purchasing electronic devices, software, services, and supplies that allow individuals to use technology in their residences to achieve greater independence and self-determination and reduce the need for staff intervention but that are not otherwise covered through other benefits in the DD Waivers or through the State Plan for Medical Assistance.
[ "Electronic visit verification" or "EVV" means a telephone, computer-based system, or other electronic technology used in real time to document, verify, and report the delivery of certain specified information about the provision of in-home or other community location, personal care, respite, companion services, and home health services. The EVV system shall report the precise time that services begin and end. ]
"Employer of record" or "EOR" means the person who performs the functions of the employer in the consumer-directed model of service delivery and may be the individual enrolled in the waiver, a family member, [ a an unpaid ] caregiver, or another designated person.
[ "Employment and community transportation" means a service offered to enable individuals to gain access to an individual's place of employment or volunteer activity, other community services or events, activities and resources, homes of family or friends, civic organizations or social clubs, public meetings or other civic activities, and spiritual activities or events as specified by the support plan and when no other means of access is available.
"Employment services organization" means providers of employment services with DARS. DARS verifies that these providers meet criteria to be providers through a DARS-recognized accrediting body. ]
"Enroll" with respect to an individual means (i) the local department of social services has determined the individual's financial eligibility for Medicaid as set out in 12VAC30-122-60; (ii) the individual has been determined by the support coordinator to be at risk of institutionalization and to meet the functional eligibility requirements in the Virginia Intellectual Developmental Disabilities Eligibility Survey form, which is referenced in 12VAC30-122-70, for the waiver; (iii) the Department of Behavioral Health and Developmental Services has verified the availability of a waiver slot for the individual; and (iv) the individual has agreed to accept the waiver slot.
"Environmental modifications" or "EM" means physical adaptations to the individual's home or primary vehicle that are necessary to ensure the individual's health and welfare or to enable functioning with greater independence.
"EPSDT" means the Early and Periodic Screening, Diagnosis and Treatment program administered by DMAS for children younger than 21 years of age according to federal guidelines that prescribe preventive and treatment services for Medicaid eligible children and as defined in 12VAC30-50-130.
"Face-to-face [ visit" contact" ] means an in-person meeting between the support coordinator and the individual and family/caregiver, as appropriate, for the purpose of assessing the individual's status and determining satisfaction with services, including the need for additional services and supports.
"Family" means, for the purpose of receiving individual and family/caregiver training services, the unpaid people who live with or provide care to an individual served by the waiver and may include a parent, a legal guardian, a spouse, children, relatives, a foster family, or in-laws but shall not include persons who are compensated [ , by any possible means, ] to care for the individual.
"FIS" means the Family and Individual Support Waiver as further described in 12VAC30-122-260.
"General supports" means staff presence to ensure that appropriate action is taken in an emergency or an unanticipated event and includes (i) awake staff during nighttime hours; (ii) routine bed checks; (iii) oversight of unstructured activities; [ or ] (iv) asleep staff at night on premises for [ security or ] safety reasons [ , or both; or (v) on-call staff ].
"Group day services" means services for the individual to acquire, retain, or improve skills of self-help, socialization, community integration, employability, and adaptation via opportunities for peer interactions, community integration, and enhancement of social networks.
"Group home residential services" means skill-building, routine supports, general supports, and safety supports that are provided in a residence licensed by DBHDS [ or an adult foster care home approved by the local department of social services ] that enable the individual to acquire, retain, or improve skills necessary to lead a self-directed life in his own community.
"Home and community-based waiver services," "HCBS," or "waiver services" means the range of community services approved by CMS pursuant to § 1915(c) of the Social Security Act to be offered to persons as an alternative to institutionalization.
"ICF/IID" means a facility or distinct part of a facility that (i) is licensed by DBHDS; (ii) meets the federal certification regulations for an intermediate care facility for individuals with intellectual disabilities and individuals with related conditions; [ and ] (iii) addresses the total needs of the individuals, which include physical, intellectual, social, emotional, and habilitation, and (iv) provides active treatment as defined in 42 CFR 483.440.
"IDEA" means the Individuals with Disabilities Education Act (20 USC § 1400 et seq.).
"Immediate family member" means [ , for the purposes of support coordination/case management services (12VAC30-50-455), ] spouses, parents [ (as "parent" is defined in this section) ], children (biological, adoptive, foster [ , step, ]) and siblings of the individual in the waiver.
[ "Independent living" means an individual living on his own with sufficient opportunities to direct his life and make informed choices, including the freedom to pursue activities fitting his capabilities and interests while maximizing full participation in community life. ]
"Individual" means the Commonwealth's citizen, including a child, who meets the income and resource standards in order to be eligible for Medicaid-covered services, has a diagnosis of developmental disability, and is eligible for the DD [ Waiver Waivers ]. The individual may be a person on the DD Waiver waiting list or an enrolled [ individual person ] who is receiving these waiver services.
"Individual support plan" or "ISP" means a comprehensive, person-centered plan that sets out the supports and actions to be taken during the year by each provider, as detailed in each provider's plan for supports to achieve desired outcomes, [ and ] goals [ , and dreams ]. The individual support plan shall be developed collaboratively by the individual, the individual's family/caregiver, as appropriate, providers, the support coordinator, and other interested parties chosen by the individual and shall contain the DMAS-approved ISP components as set forth in 12VAC30-122-190.
"Individual supported employment" means services that consist of ongoing, one-on-one supports provided by a job coach that enable the individual to be employed in an integrated work setting and may include assisting the individual to locate a job or develop a job on behalf of the individual, as well as activities needed to sustain paid work by the individual.
"Individual's responses to services" means the individual's behaviors in and responses to the [ settings services ]. In the case of an individual who does not communicate through spoken language, this shall mean the individual's condition and observable responses.
"In-home support services" means residential services that take place [ primarily ] in the individual's home, family home, or community settings that typically supplement the primary care provided to himself or by family or another unpaid caregiver and are designed to enable the individual to lead a self-directed life in the community while ensuring his health, safety, and welfare.
"Instrumental activities of daily living" or "IADLs" means skills that are [ more complex than those needed to address ADLs and that are needed to successfully live independently such as meal preparation, shopping, housekeeping, laundry, and money management. needed to successfully live independently such as meal preparation, shopping, housekeeping, laundry, and money management and do not include ADLs. ]
"Job coach" means the person who instructs individuals with disabilities utilizing structured intervention techniques to help the individual learn to perform job tasks to the employer's specifications and to learn the interpersonal skills necessary to be accepted as a worker at the job site and in related community contacts.
"LEIE" means List of Excluded Individuals and Entities. For the purpose of the use of LEIE, the use of the word "individual" shall not refer to the enrolled waiver individual.
"Levels of support" means the level (1-7) that is assigned to an individual based on the SIS® score, the results of the Virginia Supplemental Questions, and, as needed, a supporting document review verification process.
"Licensed practical nurse" or "LPN" means a person who is licensed or holds multistate licensure privilege pursuant to Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia to practice practical nursing as defined in § 54.1-3000 of the Code of Virginia.
"LMHP" means a licensed mental health professional as defined in [ 12VAC35-105-20. 12VAC30-50-130. ]
"LMHP-resident" means the same as defined in 12VAC30-50-130.
"LMHP-RP" means the same as defined in 12VAC30-50-130.
"LMHP-supervisee" means the same as defined in 12VAC30-50-130.
"Medically necessary" means an item or service provided for the diagnosis or treatment of an individual's condition consistent with community standards of medical practice [ as determined by DMAS and needed to maintain an individual in the community instead of placement in an institution ].
"Own home" means an individual residence that meets the legal definition of a residential dwelling that can be owned or leased by an individual.
"Parent" means a person who is biologically or naturally related, a foster parent, step-parent, or an adoptive parent to the individual enrolled in the waiver.
"Participating provider" means an entity that meets the standards and requirements set forth by DMAS and has a current, signed provider participation agreement with DMAS.
[ "Peer mentor supports" means information, resources, guidance, and support from an experienced, trained peer mentor to an individual who is a waiver recipient. ]
"Person-centered planning" means a fundamental process that focuses on what is important to and for an individual and the needs and preferences of the individual to create an individual support plan.
"Personal assistance service" means direct support [ or supervision ] with (i) ADLs, (ii) IADLs, (iii) access to the community, (iv) monitoring the self-administration of medication or other medical needs, and (v) monitoring health status and physical condition. Personal assistance services may occur in the home, community, work site, or postsecondary school.
"Personal assistant" means a person who provides personal assistance services employed [ either ] by a provider agency [ or under consumer direction ].
"Personal emergency response system" or "PERS" means an electronic device and monitoring service, and also may include medication monitoring units, that enable individuals to secure help in an emergency.
"Personal profile" means a point-in-time synopsis of what an individual enrolled in the waiver wants to maintain, change, improve in his life, or goals and [ dreams outcomes ] to achieve, and shall be completed by the individual and another person, such as his support coordinator or family/caregiver, chosen by the individual to help him plan before the annual planning meeting where it is discussed and then finalized to inform the individual supports plan process.
"Plan for supports" means each provider's plan for supporting the individual enrolled in the waiver in achieving the individual's desired outcomes and facilitating the individual's health and safety. The provider plan for supports is one component of the individual support plan.
"Positive behavior support" means [ an applied science that uses educational methods to expand an individual's behavior repertoire and systems change methods to redesign an individual's living environment to enhance the individual's quality of life by minimizing his challenging behaviors to enable him to lead a self-directed life in the community. a set of research-based strategies used to increase quality of life and decrease challenging behavior by teaching new skills and making changes in a person's environment. ]
"Primary caregiver" means the primary person who consistently assumes the role of providing direct care and support without compensation for such care to the individual enrolled in the waiver to enable the individual to live a self-directed life in the community.
"Private duty nursing services" means individual and continuous nursing care [ to individuals that may be provided concurrently with other services or be required by for ] individuals who have a serious medical condition or complex health care needs, or both, and that has been certified by a physician as medically necessary to enable the individual to remain in a community setting rather than in a hospital, nursing facility, or ICF/IID. [ This service may be provided concurrently with other services. ]
"Progress notes" means individual-specific written documentation that (i) contains unique differences specific to the individual's circumstances and the supports provided, and the individual's responses to such supports; (ii) is signed and dated by the person who rendered the supports; and (iii) is [ written and ] signed and dated [ as soon as is practicable but no longer than one week after the referenced service. on the day the described supports were provided. Documentation that occurs after the date supports were provided shall be dated for the date the entry is recorded and the date of supports delivery shall be noted in the body of the note. ]
"Qualified developmental disabilities professional" or "QDDP" means a professional who (i) possesses at least one year of documented experience working directly with individuals who have developmental disabilities; (ii) is one of the following: a doctor of medicine or osteopathy, a registered nurse, a provider holding at least a bachelor's degree in a human service field including sociology, social work, special education, rehabilitation engineering, counseling, or psychology; and (iii) possesses the required Virginia or national license, registration, or certification in accordance with his profession, if applicable.
"Quality management review" or "QMR" (i) means a process used by DMAS to monitor provider compliance with DMAS participation standards and policies and to ensure an individual's health, safety, and welfare and individual satisfaction with services and (ii) includes a review of the provision of services to ensure that services are being provided in accordance with DMAS regulations, policies, and procedures.
"Registered nurse" or "RN" means a person who is licensed or holds multistate licensure privilege pursuant to Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia to practice professional nursing.
"Respite services" means temporary substitute for care that is normally provided by the unpaid primary caregiver and shall be provided on a short-term basis due to the absence of or need for routine or periodic relief of the primary caregiver or other unpaid caregiver.
"Routine supports" means supports that assist the individual with ADLs and IADLs, if appropriate.
"Safety supports" means specialized assistance that is required to ensure an individual's health and safety.
"Service authorization" means the process to approve specific services for an enrolled Medicaid individual by a DMAS service authorization designee prior to service delivery and reimbursement in order to validate that the service requested is medically necessary and meets DMAS requirements for reimbursement. Service authorization does not guarantee payment for the service.
"Services facilitation" means a service that assists the individual or EOR, as appropriate, in arranging for, directing, and managing services provided through the consumer-directed model of service delivery.
"Services facilitator" means (i) a DMAS-enrolled provider, (ii) a DMAS-designated entity, or (iii) one who is employed by or contracts with a DMAS-enrolled services facilitator that is responsible for supporting the individual or EOR, as appropriate, by ensuring the development and monitoring of the plan for supports for consumer-directed services, providing employee management training, and completing ongoing review activities as required. "Services facilitator" shall be deemed to mean the same thing as "consumer-directed services facilitator."
"Shared living" means an arrangement in which a roommate resides in the same household as the individual receiving waiver services and provides an agreed-upon, limited amount of supports in exchange for which a portion of the total cost of rent, food, and utilities that can be reasonably attributed to the roommate is reimbursed to the individual.
"Skill building" means those supports that help the individual gain new skills and abilities and was previously called training.
"Skilled nursing services" means short-term nursing services (i) [ ordered by a physician and ] listed in the plan for supports that [ do not meet home health criteria, (ii) are ] not otherwise available under the State Plan for Medical Assistance, [ (iii) (ii) ] provided within the scope of § 54.1-3000 et seq. of the Code of Virginia and the Drug Control Act (§ 54.1-3400 et seq. of the Code of Virginia), and [ (iv) (iii) ] provided by a registered nurse or by a licensed practical nurse under the supervision of a registered nurse who is licensed to practice in the state or who holds a multistate [ licensing licensure ] privilege. Skilled nursing services are to be used to train and provide consultation, using nurse delegation as appropriate, and oversight of direct staff [ as appropriate consistent with the Department of Health Professions requirements for delegation of tasks ].
"Slot" means an opening or vacancy in waiver services.
[ "SSI" means social security income provided by the U.S. Social Security Administration. ]
"Sponsored residential services" means residential services that consist of skill-building, routine supports, general supports, and safety supports provided in the homes of families or persons (sponsors) who provide supports for no more than two individuals under the supervision of a DBHDS-licensed provider that enable the individuals to acquire, retain, or improve the self-help, socialization, and adaptive skills necessary to live a self-directed life in the community.
"State Plan for Medical Assistance" or "Plan" means the Commonwealth's legal document approved by CMS identifying the covered groups, covered services and their limitations, and provider reimbursement methodologies as provided for under Title XIX of the Social Security Act.
"Support coordination/case management" means assessing and planning of services; linking the individual to services and supports identified in the individual support plan; assisting the individual directly for the purpose of locating, developing, or obtaining needed services and resources; coordinating services and service planning with other agencies and providers involved with the individual; enhancing community integration; making collateral contacts to promote the implementation of the individual support plan and community integration; monitoring the individual to assess ongoing progress and ensuring that authorized services are delivered; and educating and counseling the individual to guide him to develop supportive relationships that promote the individual support plan.
"Support coordinator" means the person who provides support coordination services to an individual in accordance with [ 12VAC30-50-455 12VAC30-50-440 and 12VAC30-50-490 ]. Formerly, this was referred to as case manager and may be either an employee of a CSB or of a private entity contracted with the local CSB.
"Supported living residential [ service ]" means a service taking place in [ an apartment a residential ] setting operated by a DBHDS-licensed provider [ of supervised living residential service or supportive in-home service ] that consists of skill-building, routine supports, general supports, and safety supports that enable the individual to acquire, retain, or improve self-help [ , socialization, and adaptive ] skills necessary to live a self-directed life in home and community settings.
"Supporting documentation" means any written or electronic materials used to record and verify the individual's support needs, services provided, and contacts made on behalf of the individual and may include, for example, the personal profile, individual support plan, providers' plans for supports, progress notes, reports, medical orders, contact logs, attendance logs, and assessments.
"Supports" means paid and nonpaid assistance that promotes the accomplishment of an individual's desired outcomes. There shall be four types of supports: (i) routine supports that assist the individual in ADLs and IADLs, if appropriate; (ii) skill building supports to help the individual gain new abilities; (iii) safety supports that are required to ensure the individual's health and safety; and (iv) general supports that provide general oversight.
"Supports Intensity Scale®" or "SIS®" means an assessment tool and form that is published by the American Association on Intellectual and Developmental Disabilities and administered through a thorough interview process that measures and documents an individual's practical support requirements in personal, school-related or work-related, social, behavioral, and medical areas to suggest the types and intensity levels of the supports required by that individual to live a self-directed life in the community and to inform the discussion in the person-centered planning process.
"Therapeutic consultation" means professional consultation provided by members of psychology, social work, rehabilitation engineering, behavioral analysis, speech therapy, occupational therapy, psychiatry, psychiatric clinical nursing, therapeutic recreation, physical therapy, or behavior consultation disciplines that are designed to assist individuals, parents, family members, and any other providers of support services with implementing the individual support plan.
[ "Tiers of reimbursement" means four different rates of provider reimbursement associated with certain DD waiver services, which are tied to an individual's level of support need as determined by the Supports Intensity Scale®. ]
"Transition services" means the same as defined in 12VAC30-120-2010.
"VDSS" means the Virginia Department of Social Services.
[ "Virginia Individual Developmental Disabilities Eligibility Survey" or "VIDES" means the required level of care tool for demonstrating functional eligibility for the DD waivers. There are three types: adult, child, and infant.
"Workplace assistance service" means supports provided to an individual who has completed job development and completed or nearly completed job placement training but requires more than the typical job coach services, as in 12VAC30-122-400, to maintain stabilization in his employment. ]
12VAC30-122-30. Waiver populations; single waiver enrollment; waiver termination upon loss of eligibility.
A. The waiver services set out in 12VAC30-122-240, 12VAC30-122-250, and 12VAC30-122-260 shall be provided for eligible individuals, including children, with a developmental disability (DD) as defined in § 37.2-100 of the Code of Virginia and who have been determined to require the level of care provided in an ICF/IID. These services can only be covered if required by the individual to avoid institutionalization. These services shall be appropriate and [ medically ] necessary to ensure community integration.
B. An individual shall not be simultaneously enrolled in more than one waiver. An individual who has a diagnosis of DD may be on the waiting list for one of the DD Waivers (FIS, CL, or BI) while simultaneously being enrolled in the Elderly or Disabled with Consumer Direction (EDCD) (12VAC30-120-900 et seq.) or the Technology Assisted (12VAC30-120-1700 et seq.) waivers if he meets applicable criteria for either.
C. DMAS or its designee shall ensure only eligible individuals receive home and community-based waiver services and shall terminate the individual from the waiver and such services when the individual is no longer eligible for the waiver. Termination from the DD Waivers shall occur when, for example, (i) the individual's health, safety, and welfare and medical needs can no longer be safely met in the community; (ii) when the individual is no longer eligible for either Medicaid or no longer meets the ICF/IID level of care; or (iii) when the individual was eligible for one of the waivers and accepted a waiver slot but did not start services for five months.
12VAC30-122-40. Waiver services; when not authorized.
A. The FIS, CL, and BI waiver services, collectively known as Developmental Disabilities (DD) Waivers, shall not be authorized or reimbursed by DMAS for an individual who resides outside of the physical boundaries of the Commonwealth.
B. Waiver services [ (with the exception of transition services) ] shall not be furnished to individuals who are inpatients of a hospital, nursing facility, ICF/IID, or inpatient rehabilitation facility. Individuals with DD who are inpatients of these facilities may receive [ service support ] coordination services as described in 12VAC30-50-440 [ or 12VAC30-50-490 ].
1. The support coordinator may recommend waiver services that would promote the individual's exiting from an institutional placement.
2. However, the FIS, CL, or BI waiver services shall not be provided until the individual has exited the institution and has been enrolled in the waiver.
C. DMAS shall not reimburse providers for the costs of room and board [ attributed to the member ], education, services covered by other payers, or participation in social or recreational activities.
12VAC30-122-45. Waiver slot allocation process.
A. When the General Assembly has approved less than 40 slots for a given waiver, the available slots will be allocated by DBHDS to regions or sub-regions of the state for distribution to the individuals in that region or sub-region who are determined to have the most urgent needs. If there are BI slots to be allocated, the BI slots will be allocated by region.
B. When at least 40 new waiver slots are funded by the General Assembly, one slot will be allocated by DBHDS to each CSB. Additional slots up to the total number of available slots for a given waiver will be allocated by DBHDS to CSBs for individuals living within that CSB's catchment area based upon the following objective factors and criteria:
1. The region's population;
2. The percentage of Medicaid eligible individuals in the catchment area; and
3. Each CSB's percentage of individuals on the "Priority One" portion of the statewide waiting list.
12VAC30-122-50. Criteria for all individuals seeking Developmental Disability Waivers services.
The following [ four three ] criteria shall apply to all individuals who seek DD Waivers services:
1. The need for DD Waivers services shall arise from an individual having a diagnosed condition of developmental disability as defined in § 37.2-100 of the Code of Virginia. [ Individuals qualifying for the DD Waivers services shall have a demonstrated need for the covered services due to significant functional limitations in major life activities, as demonstrated on their Virginia Individual Developmental Disabilities Eligibility Survey (VIDES) forms, and shall be at risk of institutionalization. ]
2. Individuals qualifying for the DD Waivers services shall meet the level-of-care provided in an ICF/IID [ as set forth in the VIDES ] and shall demonstrate this need at least annually consistent with 42 CFR 441.302. [ 3. The results of an individual's Virginia Individual Developmental Disabilities Eligibility Survey (VIDES) determination shall be one element in determining if the individual qualifies for the DD Waivers (either in the FIS, CL, or BI waiver). This is demonstrated by having significant functional limitations in major life activities as documented on their VIDES forms. ] The [ Commonwealth shall use ] VIDES forms [ shall be ] conducted in person [ and, unless the individual to be screened resides out of state, ] by a qualified support coordinator to establish [ if the individual meets ] the level of care required for [ its the ] DD Waivers.
a. VIDES for infants shall be used for the evaluation of individuals who are younger than three years of age (DMAS-P235).
b. VIDES for children shall be used for the evaluation of individuals who are three years of age through 17 years of age (DMAS-P-236).
c. VIDES for adults shall be used for the evaluation of individuals who are 18 years of age and older (DMAS-P237).
[ 4. The 3. Once assigned a waiver slot, the ] individual shall meet the financial eligibility criteria set out in 12VAC30-122-60.
[ 5. 4. Individuals shall indicate their willingness to accept waiver services within 30 days of slot assignment. ]
12VAC30-122-60. Financial eligibility standards for individuals.
A. Individuals receiving services under the Family and Individual Supports (FIS) Waiver, Community Living (CL) Waiver, and Building Independence (BI) Waiver, which are collectively known as the DD Waivers, shall meet the following Medicaid eligibility requirements. The Commonwealth shall apply the financial eligibility criteria contained in the State Plan for Medical Assistance for the categorically needy and in 12VAC30-30-10 and 12VAC30-40-10. The Commonwealth covers the optional categorically needy groups under 42 CFR 435.211, 42 CFR 435.217, and 42 CFR 435.230.
B. Patient pay methodology.
1. The income level used for 42 CFR 435.211, 42 CFR 435.217, and 42 CFR 435.230 shall be 300% of the current supplemental security income (SSI) payment standard for one person.
2. Under the DD Waivers, the coverage groups authorized under § 1902(a)(10)(A)(ii)(VI) of the Social Security Act shall be considered as if they were institutionalized for the purpose of applying institutional deeming rules. All individuals under the waivers shall meet the financial and nonfinancial Medicaid eligibility criteria and meet the institutional level-of-care criteria for an ICF/IID. The deeming rules shall be applied to waiver eligible individuals as if the individuals were residing in an ICF/IID or would require that level of care.
3. The Commonwealth shall reduce its payment for home and community-based waiver services provided to an individual who is eligible for Medicaid services under 42 CFR 435.217 by that amount of the individual's total income, including amounts disregarded in determining eligibility, that remains after allowable deductions for personal maintenance needs, other dependents, and medical needs have been made according to the guidelines in 42 CFR 435.735 and § 1915(c)(3) of the Social Security Act as amended by the Consolidated Omnibus Budget Reconciliation Act of 1986 (42 USC § 1395ww). DMAS shall reduce its payment for home and community-based waiver services by the amount that remains after the deductions listed in this subdivision:
a. For individuals to whom § 1924(d) of the Social Security Act applies and for whom the Commonwealth waives the requirement for comparability pursuant to § 1902(a)(10)(B), DMAS shall deduct the following in the respective order:
(1) The basic maintenance needs for an individual under the DD Waivers, which shall be equal to 165% of the SSI payment for one person. Due to expenses of employment, a working individual shall have an additional income allowance. For an individual employed 20 hours or more per week, earned income shall be disregarded up to a maximum of both earned and unearned income up to 300% of SSI; for an individual employed [ at least eight but ] less than 20 hours per week, earned income shall be disregarded up to a maximum of both earned and unearned income up to 200% of SSI. If the individual requires a guardian or conservator who charges a fee, the fee, not to exceed an amount greater than 5.0% of the individual's total monthly income, shall be added to the maintenance needs allowance. However, in no case shall the total amount of the maintenance needs allowance (basic allowance plus earned income allowance plus guardianship fees) for the individual exceed 300% of SSI.
(2) For an individual with only a spouse at home, the community spousal income allowance determined in accordance with § 1924(d) of the Social Security Act.
(3) For an individual with a family at home, an additional amount for the maintenance needs of the family determined in accordance with § 1924(d) of the Social Security Act.
(4) Amounts for incurred expenses for medical or remedial care that are not subject to payment by a third party including Medicare and other health insurance premiums, deductibles, or coinsurance charges, and necessary medical or remedial care recognized under state law but not covered under the State Plan for Medical Assistance.
b. For individuals to whom § 1924(d) does not apply and for whom the Commonwealth waives the requirement for comparability pursuant to § 1902(a)(10)(B), DMAS shall deduct the following in the respective order:
(1) The basic maintenance needs for an individual under the DD Waivers, which is equal to 165% of the SSI payment for one person. Due to expenses of employment, a working individual shall have an additional income allowance. For an individual employed 20 hours or more per week, earned income shall be disregarded up to a maximum of both earned and unearned income up to 300% of SSI; for an individual employed [ at least eight but ] less than 20 hours per week, earned income shall be disregarded up to a maximum of both earned and unearned income up to 200% of SSI. If the individual requires a guardian or conservator who charges a fee, the fee, not to exceed an amount greater than 5.0% of the individual's total monthly income, shall be added to the maintenance needs allowance. However, in no case shall the total amount of the maintenance needs allowance (basic allowance plus earned income allowance plus guardianship fees) for the individual exceed 300% of SSI.
(2) For an individual with a dependent child, an additional amount for the maintenance needs of the child, which shall be equal to the Title XIX medically needy income standard based on the number of dependent children.
(3) Amounts for incurred expenses for medical or remedial care that are not subject to payment by a third party including Medicare and other health insurance premiums, deductibles, or coinsurance charges, and necessary medical or remedial care recognized under state law but not covered under the State Plan for Medical Assistance.
12VAC30-122-70. Assessment and enrollment; Virginia Individual Developmental Disabilities Eligibility Survey.
A. Home and community-based waiver services shall be considered only for individuals eligible for admission to an ICF/IID due to the individuals' diagnoses of developmental disabilities and documented functional support needs. For the support coordinator to make a recommendation for the DD Waivers services, the services shall be determined to be an appropriate service alternative to delay or avoid placement in an ICF/IID or to promote exiting from an ICF/IID or other institutional placement provided that a viable discharge plan that preserves the individual's health, safety, and welfare in the community has been developed.
B. The support coordinator shall confirm diagnostic and functional eligibility for individuals with input from the individual and the individual's family/caregiver, as appropriate, and service or support providers involved in the individual's support prior to DMAS assuming payment responsibility for covered home and community-based waiver services. This confirmation shall be accomplished through the completion of the following:
1. A psychological or other evaluation of the individual that affirms that the individual meets the diagnostic criteria for developmental disability as defined in § 37.2-100 of the Code of Virginia; and
2. The required level-of-care determination through the Virginia [ Intellectual Individual ] Developmental Disabilities Eligibility Survey (VIDES) appropriate to the individual according to his age, completed no more than six months prior to waiver enrollment.
C. To receive waiver services, the individual shall be found to be eligible for Medicaid pursuant to 12VAC30-122-60.
D. The individual who has been found to be eligible for these services consistent with subsections A [ , and ] B [ , and C ] in this section shall be given by the support coordinator his choice of either institutional placement or receipt of home and community-based waiver services.
E. If the individual chooses home and community-based waiver services and an ISP that ensures the individual's safety can be developed, then the support coordinator shall recommend the individual for home and community-based waiver services.
F. [ If Consistent with 12VAC30-122-90 E, if ] the individual selects waiver services and a slot is available, then the support coordinator shall enroll the individual in the waiver. The CSB or BHA shall only enroll the individual following electronic confirmation by DBHDS that a slot is available.
G. If no slot is available, the support coordinator shall place the individual on the DD Waivers waiting list consistent with criteria established for the DD Waivers in 12VAC30-122-90 until such time as a slot becomes available. Once the individual's name has been placed on the DD Waivers waiting list, the support coordinator shall (i) notify the individual in writing within 10 business days of his placement on the DD Waivers waiting list and his assigned prioritization level, as set out in 12VAC30-122-90, and (ii) offer appeal rights pursuant to 12VAC30-110.
H. There shall be documentation of contact with the individual at least annually while the individual is on the waiting list to provide the choice between institutional placement and waiver services consistent with the requirements of 12VAC30-50-440 or 12VAC30-50-490, as applicable.
[ I. Every place in this chapter that requires physician action, DMAS permits nurse practitioners to perform those tasks in accordance with § 54.1-2957 of the Code of Virginia. ]
12VAC30-122-80. Waiver approval process; authorizing and accessing services.
A. The support coordinator [ shall electronically submit enrollment information to DBHDS to confirm level-of-care eligibility once he has determined (i) an individual meets the functional criteria for FIS, CL, or BI waiver services, (ii) that a slot is available, and (iii) the individual has chosen waiver services is notified that a slot is available when the regional supports specialist (RSS) moves the individual to projected enrollment status in the Virginia Waiver Management System (WaMS). The support coordinator shall notify the individual and family/caregiver of slot availability and available services within the offered waiver within seven calendar days of the waiver slot assignment date.
B. The individual/caregiver will confirm acceptance or declination of the slot within 15 calendar days of notification of slot availability.
C. The individual and the individual's family/caregiver, as appropriate, shall meet with the support coordinator within 30 calendar days of the waiver assignment date to (i) discuss the individual's assessed needs, existing supports, and individual preferences; (ii) discuss obtaining a medical examination, which shall have been completed no earlier than 12 months prior to the initiation of waiver services; (iii) begin to develop the personal profile; and (iv) discuss the completion of the assessment as required by 12VAC30-122-200.
D. Prior to or at the meeting to discuss the individual's assessed needs, the support coordinator shall provide the individual with a choice of services identified as needed and available in the assigned waiver, providers, and settings alternatives ].
[ B. Once the individual has been notified of an available waiver slot E. After the individual has accepted the waiver slot offered ] by the CSB or BHA, the support coordinator shall submit a DMAS-225 (Medicaid Long-Term Care Communication Form) along with a computer-generated confirmation of level-of-care eligibility to the local department of social services to determine financial eligibility for Medicaid and the waiver and any patient pay responsibilities. The DMAS-225 is the form used by the support coordinator to report information about patient pay amount changes in an individual's situation.
[ C. F. ] After the support coordinator has received written notification of Medicaid eligibility from the local department of social services, the support coordinator shall inform the individual, submit information to DMAS or its designee to enroll the individual in the waiver, and develop the person-centered individual support plan (ISP).
[ 1. The individual and the individual's family/caregiver, as appropriate, shall meet with the support coordinator within 30 calendar days of the waiver enrollment date to (i) discuss the individual's assessed needs, existing supports, and individual preferences and then obtain a medical examination, which shall have been completed no earlier than 12 months prior to the initiation of waiver services; (ii) begin to develop the personal profile; and (iii) schedule the completion of the assessment as required by 12VAC30-122-200.
2. The support coordinator shall provide the individual with a choice of services identified as needed and available in the assigned waiver, alternative settings, and providers. ]
[ G. ] Once the providers are chosen, a planning meeting shall be held by the support coordinator to develop the ISP based on the individual's assessed needs, the individual's preferences, and the individual's family/caregiver preferences, as appropriate.
[ 3. H. ] Persons invited by the support coordinator to participate in the person-centered planning meeting may include the individual, providers, and others as desired by the individual. During the person-centered planning meeting, the services to be rendered to the individual, the frequency of services, the type of provider, and a description of the services to be offered are identified and included in the ISP. At a minimum, the individual enrolled in the waiver, [ or and ] the family/caregiver as appropriate, and support coordinator shall sign and date the ISP.
[ 4. I. ] The individual, family/caregiver, or support coordinator shall contact chosen providers so that services can be initiated within 30 calendar days of [ receipt of written confirmation of waiver the support coordinator moving the individual to active ] enrollment [ status in WaMS or confirmation of Medicaid eligibility whichever comes last ]. If the services are not initiated by the provider within 30 days, the support coordinator shall notify the local department of social services so that reevaluation of the individual's financial eligibility can be made.
[ 5. In the case of an individual being referred back to a local department of social services for a redetermination of eligibility and to retain the designated slot, the support coordinator shall, at the same time as submission of notification to the local department of social services, electronically submit information to DBHDS requesting retention of the designated slot pending the initiation of services J. In the event services are not initiated within 30 calendar days and the individual wishes to retain the waiver slot, the support coordinator will electronically submit a request in WaMS to retain the designated slot pending the initiation of services ].
[ a. 1. ] A copy of the request shall be provided to the individual and the individual's family/caregiver, as appropriate.
[ b. 2. After receipt and approval of the first request to retain the slot, ] DBHDS shall have the authority to approve the slot-retention request in 30-day extensions, up to a maximum of four consecutive extensions, or deny such request to retain the waiver slot for the individual when at the end of [ this each ] extension time period there is no evidence of the individual's efforts to utilize waiver services. All written denial notifications to the individual, and family/caregiver, as appropriate, shall be accompanied by the standard appeal rights (12VAC30-110).
[ c. 3. ] DBHDS shall provide an electronic response to the support coordinator indicating denial or approval of the slot extension request [ . DBHDS shall submit this response to the support coordinator ] within 10 working days of the receipt of the request for extension.
[ d. 4. ] The support coordinator shall notify the individual in writing of any denial of the slot extension request and the individual's right to appeal.
[ 6. K. ] The providers, in conjunction with the individual and the individual's family/caregiver, as appropriate, and the support coordinator shall develop a plan for supports for each service.
[ a. 1. ] Each provider shall submit a copy of his plan for supports to the support coordinator. The plan for supports from each provider shall be incorporated into the ISP. The ISP shall also contain [ the identified risks and ] the steps for mitigating any identified risks.
[ b. 2. ] The support coordinator shall review and ensure the provider-specific plan for supports meets the established service criteria for the identified needs prior to electronically submitting the plan for supports along with the results of the comprehensive assessment and a recommendation for the final determination of the need for ICF/IID level of care to DMAS or its designee for service authorization. "Comprehensive assessment" means the gathering of relevant social, psychological, medical, and level of care information by the support coordinator that are used as bases for the development of the individual support plan.
[ c. 3. ] DMAS or its designee shall, within 10 working days of receiving all supporting documentation, review and approve, suspend for more information, or deny the individual service requests. DMAS or its designee shall communicate electronically to the support coordinator whether the recommended services have been approved and the amounts and types of services authorized or if any services have been denied.
[ d. 4. ] Only waiver services authorized on the ISP by the state-designated agency or its designee shall be reimbursed by DMAS.
[ 7. L. ] DMAS shall not pay for any home and community-based waiver services delivered prior to the authorization date approved by DMAS or its designee if service authorization is required.
[ 8. M. ] Waiver services shall be approved and authorized by DMAS or its designee only if:
[ a. 1. ] The individual is Medicaid eligible as determined by the local department of social services;
[ b. 2. ] The individual has a diagnosis of developmental disability, as defined by § 37.2-100 of the Code of Virginia, and would, in the absence of waiver services, require the level of care provided in an ICF/IID that would be reimbursed under the State Plan for Medical Assistance;
[ c. 3. ] The individual's ISP can be safely rendered in the community; and
[ d. 4. ] The contents of providers' plans for supports are consistent with the ISP requirements, limitation, units, and documentation requirements of each service.
12VAC30-122-90. Waiting list; criteria; slot assignment; emergency access; reserve slots.
A. There shall be a current and accurate statewide waiting list, called the DD Waivers waiting list, for the DD Waivers. This waiting list shall be created and maintained by DBHDS, which shall update it no less than annually.
B. Individuals on this waiting list shall have (i) a diagnosis of developmental disability pursuant to § 37.2-100 of the Code of Virginia, (ii) a completed VIDES form, and (iii) a priority designation consistent with subsection [ C D ] of this section.
C. [ Individuals who accompany parents or guardians deployed overseas for active duty U.S. military or Foreign Service assignment but retain Virginia residency shall remain on the statewide DD Waivers waiting list and be considered for DD Waivers slot assignment when they are within three months of returning to Virginia. ]
D. ] To be placed in one of the following prioritization levels, the support coordinator shall determine through inquiry of the individual and family/caregiver, as appropriate, and consideration of the information reflected in the individual's diagnosis and VIDES form, which [ priority ] category the individual meets. The individual shall be placed in the prioritization level that best describes his need for waiver services by meeting at least one criterion in the category:
1. Priority One shall include individuals who require a waiver service within one year and are determined to meet at least one of the following criteria:
a. An immediate jeopardy exists to the health and safety of the individual due to the unpaid primary caregiver having a chronic or long-term physical or psychiatric condition that currently significantly limits the ability of the primary caregiver to care for the individual; [ or ] there are no other unpaid caregivers available to provide supports;
b. There is immediate risk to the health or safety of the individual, primary caregiver, or other person living in the home due to either of the following conditions:
(1) The individual's behavior, presenting a risk to himself or others, cannot be effectively managed [ by the primary caregiver or unpaid provider ] even with support coordinator-arranged generic or specialized supports; or
(2) There are physical care needs or medical needs that cannot be managed [ by the primary caregiver ] even with support coordinator-arranged generic or specialized supports;
c. The individual lives in an institutional setting and has a viable discharge plan; or
d. The individual is a young adult who is no longer eligible for IDEA services and [ is transitioning to independent living has expressed a desire to live independently ]. After individuals attain 27 years of age, this criterion shall no longer apply.
2. Priority Two shall include individuals who will need a waiver service in one to five years and are determined to meet at least one of the following criteria:
a. The health and safety of the individual is likely to be in future jeopardy due to:
(1) The unpaid primary caregiver having a declining chronic or long-term physical or psychiatric condition that currently significantly limits his ability to care for the individual;
(2) There are currently no other unpaid caregivers available to provide supports; [ and or ]
(3) The individual's skills are declining as a result of lack of supports;
b. The individual is at risk of losing employment supports;
c. The individual is at risk of losing current housing due to a lack of adequate supports and services; or
d. The individual has needs or desired outcomes that with adequate supports will result in a significantly improved quality of life.
3. Priority Three shall include individuals who will need a waiver slot in five years or longer as long as the current supports and services remain and have been determined to meet at least one of the following criteria:
a. The individual is receiving a service through another funding source that meets current needs;
b. The individual is not currently receiving a service but is likely to need a service in five or more years; or
c. The individual has needs or desired outcomes that with adequate supports will result in a significantly improved quality of life.
[ D. Individuals and family/caregivers shall have the right to appeal the application of the prioritization criteria, emergency criteria, or reserve criteria to their circumstances pursuant to 12VAC30-110. All notifications of appeal shall be submitted to DMAS. ]
E. Waiver slots shall be assigned subject to available funding.
1. A Waiver Slot Assignment Committee (WSAC) is the impartial body of trained volunteers established for each locality or region with responsibility for recommending individuals eligible for a waiver slot according to their urgency of need. All WSACs shall be composed of community members who shall not be employees of a CSB or a private provider of either support coordination or waiver services and shall be knowledgeable and have experience in the developmental disabilities service system.
2. For FIS and CL waiver slots, individuals who are in the Priority One category who are determined to be most in need of supports at the time a slot is available shall be reviewed by an independent WSAC for the area in which the slot is available. [ The determination of which individuals in Priority One are to be reviewed by the WSAC is accomplished through completion by the support coordinator of the Critical Needs Summary-Step 1 Review Form (CNS), which assigns numeric ratings to various circumstances that are deemed to affect urgency of need. A Slot Assignment Review Form (SARF), also completed by the support coordinator, is given to the WSAC members for each individual in the review pool in order to provide the committee with information about the individuals' needs, current services, and DD Waiver services that would best meet their needs.
3. ] The individual who has the highest need as designated by the committee shall be recommended for the available waiver slot. DBHDS shall make the final determination for slot assignment [and to the most appropriate waiver to address the assessed needs of the individual. FIS slots will be offered unless the individual demonstrates an immediate need for sponsored residential, group home residential, or support living which are only offered in the CL waiver ].
3. For BI waiver slots, each of five regional WSACs composed of one representative from each existing WSAC within the region shall make assignment recommendations for BI waiver slots. If the number of individuals interested in a BI waiver slot with Priority One status for all CSBs in a region is less than the number of available slots, those individuals are assigned a slot without a regional WSAC session occurring. A regional WSAC session will then be held for the remainder of available slots, reviewing those individuals meeting criteria for Priority Two and then Priority Three.
F. If the individual determines at any time that he no longer wishes to be on the DD Waiver waiting list, he may contact his support coordinator to request removal from the waiting list. The support coordinator shall notify DBHDS so that the individual's name can be removed from the waiting list.
G. Eligibility criteria for emergency access to either the FIS, CL, or BI waiver.
1. Subject to available funding of waiver slots and a finding of eligibility under 12VAC30-122-50 and 12VAC30-122-60, individuals shall meet at least one of the emergency criteria of this subdivision to be eligible for immediate access to waiver services without consideration to the length of time they have been waiting to access services. The criteria shall be one of the following:
a. Child protective services has substantiated abuse or neglect against the primary caregiver and has removed the individual from the home; or for adults where (i) adult protective services has found that the individual needs and accepts protective services or (ii) abuse or neglect has not been founded, but corroborating information from other sources (agencies) indicate that there is an inherent risk present and there are no other caregivers available to provide support services to the individual.
b. Death of primary caregiver or lack of alternative caregiver coupled with the individual's inability to care for himself and endangerment to self or others without supports.
[ c. An individual who transitioned from one of the DD Waivers to the Medicaid Works program who chooses to resume DD Waiver services. ]
2. Requests for emergency slots shall be forwarded by the CSB or BHA to DBHDS.
a. Emergency slots may be assigned by DBHDS to individuals until the total number of available emergency slots statewide reaches 10% of the emergency slots funded for a given fiscal year, or a minimum of three slots. At that point, the next nonemergency waiver slot that becomes available at the CSB or BHA in receipt of an emergency slot shall be reassigned to the emergency slot pool to ensure emergency slots remain to be assigned to future emergencies within the Commonwealth's fiscal year.
b. Emergency slots shall also be set aside for those individuals [ not previously identified but newly known as needing supports resulting from an emergent situation meeting eligibility criteria and not on the DD Waivers waiting list but newly identified as meeting all eligibility criteria and in need of supports resulting from an emergent situation described in subdivision 1 of this subsection ].
H. Reserve slots and the reserve waiting list.
1. Reserve slots may be used for transitioning an individual who, due to (i) [ a ] documented [ changes change ] in his [ assessed ] support needs [ , which requires a service that is not available in the DD Waiver in which the individual is presently enrolled ] or (ii) a preference for supports found in a waiver with a less comprehensive array of supports, requires [ or and ] requests a move from the DD Waiver in which he is presently enrolled into another of the DD Waivers to access necessary services.
a. An individual who needs to transition between the DD Waivers shall not be placed on the DD Waivers waiting list.
[ b. A documented change in an individual's assessed needs, which requires a service that is not available in the DD Waivers in which the individual is presently enrolled, shall exist for an individual to be considered for a reserve slot.
c. b. ] CSBs or BHAs shall document and notify DBHDS in writing when an individual meets the criteria in subdivision 1 b of this subsection within three business days of knowledge of need. The assignment of reserve slots shall be managed by DBHDS, which will maintain a chronological list of individuals in need of a reserve slot in the event that the reserve slot supply is exhausted. Within three business days of adding an individual's name to the reserve slot list, DBHDS shall advise the individual in writing that his name is on the reserve slot list and his chronological placement on the list.
[ d. c. ] Within three business days of receiving a request from an individual for a status update regarding his placement on the list, DBHDS shall advise the individual of his current chronological list number.
2. When a reserve slot becomes available and an individual is identified from the chronological list to access the slot, the support coordinator will assure to DBHDS that the service that warranted the transfer to the new waiver (e.g., group home residential) is (i) identified and (ii) a targeted date of service initiation is in place prior to the reserve slot assignment to the new waiver.
3. When an individual transitions to a new DD waiver using a reserve slot, the waiver slot vacated by that individual shall be offered to the next individual in that CSB's chronological queue for a reserve slot by DBHDS. If the individual chooses to accept the slot, DBHDS will assign in accordance with subdivision 2 of this subsection. [ The individual receiving that slot must initiate services with the service that made him eligible for the reserve waiting list within 60 calendar days. If he is unable to initiate those services, he will remain in the slot he currently occupies and may remain on the reserve slot waiting list until another slot becomes available.
4. ] If there is not an individual in that CSB's chronological queue for a reserve slot, the vacated slot will be assigned to an individual on the statewide waiting list who resides in the CSB's or BHA's catchment area by DBHDS after review and recommendations from the local WSAC.
[ 4. 5. ] When a slot is vacated in one of the DD Waivers (e.g., due to the death of an individual), the slot shall be assigned to the next individual in that CSB's chronological queue for a reserve slot in accordance with the procedures outlined in subdivision 3 of this subsection.
[ I. Individuals and family/caregivers shall have the right to appeal the application of the prioritization criteria, emergency criteria, or reserve criteria to their circumstances pursuant to 12VAC30-110. All notifications of appeal shall be submitted to DMAS. ]
12VAC30-122-100. Modifications to or termination of services.
A. DMAS or its designee shall have the authority to approve modifications to an individual's ISP, based on the recommendations of the support [ coordination provider coordinator ].
B. The provider shall be responsible for modifying an individual's plan for supports, with the involvement of the individual enrolled in the waiver and the individual's family/caregiver, as appropriate, and submitting such revised plan for supports to the support coordinator any time there is a modification in the individual's condition or circumstances that may warrant a change in the amount or type of service rendered by the provider.
1. The support coordinator shall review the need for a modification and may recommend a modification to the plan for supports to DBHDS. If the support coordinator does not recommend a modification to the plan for supports and that results in the denial of the requested service, the support coordinator shall inform the individual of his right to appeal.
2. DBHDS shall approve, deny, or pend for additional information the provider's requested modification to the individual's plan for supports as recommended by the support coordinator. DBHDS shall communicate its determination to the support coordinator within 10 business days of receiving all supporting documentation regarding the request for modification or in the case of an emergency, within three business days of receipt of the request for modification.
3. The individual enrolled in the waiver and the individual's family/caregiver, as appropriate, shall be notified in writing by the support coordinator of his right to appeal, pursuant to DMAS client appeals regulations (12VAC30-110), all decisions to reduce, [ suspend, ] deny, or terminate services. The support coordinator shall submit this written notification to the individual enrolled in the waiver or the family/caregiver, as appropriate, within 10 business days of the decision. Once the individual or family/caregiver receives the written notification, the clock for filing an appeal, as set forth in the DMAS client appeals regulations, shall begin to run.
C. In an emergency situation when the health, safety, or welfare of the individual enrolled in the waiver, other individuals in that setting, or provider personnel are endangered, the support coordinator and DBHDS shall be notified by the provider prior to discontinuing services. The 10-business-day prior written notification period shall not be required. The local department of social services adult protective services unit or child protective services unit, as appropriate, and the DBHDS Offices of Licensing and Human Rights and DMAS shall be notified immediately of the emergency discontinuation of services by the support coordinator and the provider when the individual's health, safety, or welfare may be in danger.
D. In a nonemergency situation, when a provider determines that his provision of supports to an individual enrolled in the waiver will be discontinued, the provider shall give the individual and the individual's family/caregiver, as appropriate, and support coordinator written notification of the provider's intent to discontinue services. The notification letter shall provide the reasons for the planned discontinuation and the effective date the provider will be discontinuing services. The effective date of the service discontinuation shall be at least 10 business days after the date of the notification letter. The individual enrolled in the waiver may seek services from another enrolled provider. When an individual is transitioning to a different provider, the former provider that served [ said the ] individual shall, at the request of the [ new ] provider, provide all medical records and documentation of services to the new provider [ (consistent with confidentiality requirements, including the Health Insurance Portability and Accountability Act and 12VAC35-115, Regulations to Assure the Rights of Individuals Receiving Services from Providers Licensed, Funded, or Operated by the Department of Behavioral Health and Developmental Services) ] to ensure high quality continuity of care and service provision.
E. To discontinue services in both emergency and nonemergency situations, providers of group home residential services, supported living residential services, and sponsored residential services shall comply with the terms set forth in an individual's home and community-based settings residency or lease agreement as described in 42 CFR 441.301.
F. [ Support coordinators must inform DBHDS when an individual transitions from one of the DD Waivers to the Medicaid Works program. Such individuals may retain their DD Waiver slot for 180 days after the date of transition, although DD Waiver services must be closed. After the 150-day period, DBHDS will notify the support coordinator of the need to take action to terminate the slot. The support coordinator will notify the individual and family/caregiver, as appropriate, of this determination and the right to appeal, pursuant to 12VAC30-110, such termination in advance of the action.
G. ] The support coordinator shall have the responsibility to identify those individuals who no longer meet the level of functioning criteria [ (VIDES) ] or for whom home and community-based waiver services are no longer an appropriate alternative. In such situations, DMAS or its designee shall terminate such individuals from the waiver.
1. The support coordinator shall notify the individual and family/caregiver, as appropriate, of this determination and the right to appeal, pursuant to 12VAC30-110, such termination.
2. The individual shall be given the option to continue his waiver services pending the final outcome of his appeal. Should the outcome of the appeal confirm the determination by DMAS or its designee that the individual should be terminated from the waiver, the individual [ shall may ] be responsible for the costs of his waiver services incurred by DMAS during his appeal [ as required by 12VAC 30-110-100 ].
12VAC30-122-110. Waiver provider enrollment.
DMAS or its designee shall be responsible for assuring continued adherence to provider participation standards. DMAS or its designee shall conduct ongoing monitoring of compliance with provider participation standards and applicable laws [ and, ] regulations [ , and DMAS policies ]. A provider's noncompliance with applicable federal and state Medicaid laws [ and, ] regulations, [ and DMAS policies ] as required in the provider's participation agreement, may result in termination of the provider participation agreement. For DMAS to approve enrollment of a provider for home and community-based waiver services, the following standards shall be met:
1. Licensure or certification requirements, or both as applicable, for services that have licensure or certification requirements;
2. Disclosure of ownership pursuant to 42 CFR 455.104, 42 CFR 455.105, and 42 CFR 455.106; and
3. The ability to document and maintain individual records in accordance with federal and state requirements.
12VAC30-122-120. Provider requirements.
A. Providers approved for participation shall at a minimum perform the following activities:
1. On a monthly basis, screen and document the names of all new and existing employees and contractors to determine whether any are excluded from eligibility for payment from federal health care programs, including Medicaid (i.e., via the U.S. Department of Health and Human Services Office of Inspector General List of Excluded Individuals and Entities (LEIE) website). Immediately upon learning of an exclusion, report in writing to DMAS such exclusion information to: DMAS, ATTN: Program Integrity/Exclusions, 600 East Broad Street, Suite 1300, Richmond, VA 23219 or email to providerexclusion@dmas.virginia.gov.
2. Immediately notify DMAS in writing of any change in the information that the provider previously submitted for the purpose of the provider agreement to DMAS.
3. Assure the individual's freedom to refuse medical care, treatment, and services and document that potential adverse outcomes that may result from refusal of services were discussed with the individual.
4. Accept referrals for services only when staff is available to initiate services within 30 calendar days of the referral and perform such services on an ongoing basis.
5. [ Accept training on Crisis Education and Prevention Plans (CEPPs) by DBHDS, or its contractor, based on individual needs.
6. Participate in the completion of Quality Service Reviews conducted by DBHDS or its contractor. ]
7. ] Provide medically necessary services and [ supplies supports ] for individuals in accordance with the ISP and in full compliance with 42 CFR 441.301, which provides for person-centered planning and other requirements for home and community-based settings including the additional requirements for provider-owned and controlled residential settings; Title VI of the Civil Rights Act of 1964, as amended (42 USC § 2000d et seq.), which prohibits discrimination on the grounds of race, color, or national origin; the Virginians with Disabilities Act (Title 51.5 (§ 51.5-1 et seq.) of the Code of Virginia); § 504 of the Rehabilitation Act of 1973, as amended (29 USC § 794), which prohibits discrimination on the basis of a disability; and the Americans with Disabilities Act, as amended (42 USC § 12101 et seq.) [ , which provides comprehensive civil rights protections to individuals with disabilities in the areas of employment, public accommodations, state and local government services, and telecommunications ].
[ 6. 8. ] Provide services and [ supplies supports ] to individuals of the same quality and in the same mode of delivery as provided to the general public.
[ 7. 9. ] In addition to compliance with the general conditions and requirements, all providers enrolled by DMAS shall adhere to the requirements outlined in federal and state laws, regulations, DMAS provider manuals, and their individual provider participation agreements.
[ 8. 10. ] Submit reimbursement claims to DMAS for the provision of covered services and supplies for individuals in amounts not to exceed the provider's usual and customary charges to the general public and accept as payment in full the amount established by the DMAS payment methodology from the individual's authorization date for that waiver service.
[ 9. 11. ] Use program-designated billing forms for submission of claims for reimbursement.
[ 10. 12. ] Maintain and retain business records (e.g., licensing or certification records as appropriate) and professional records (e.g., staff training and criminal record check documentation). All providers, including services facilitation providers, shall also document fully and accurately the nature, scope, and details of the services provided to support claims for reimbursement. Provider documentation that fails to fully and accurately document the nature, scope, and details of the services provided may be subject to recovery actions by DMAS or its designee. Provider documentation responsibilities include the following:
a. Retain records for at least six years from the last date of service or as provided by applicable state and federal laws, whichever period is longer. Records of minors shall be kept for at least six years after such minor has reached the age of 18 years.
b. If an audit is initiated of the provider's records within the required retention period, the records shall be retained until the audit is completed and every exception resolved. No business or professional records that are subject to the audit shall be created or modified by providers, employees, or any other interested parties, either with or without the provider's knowledge, once an audit has been initiated.
c. Policies regarding retention of records shall apply even if the provider discontinues operation. Providers shall notify DMAS in writing of storage, location, and procedures for obtaining records for review should the need arise. The location, agent, or trustee of the provider's records shall be within the Commonwealth of Virginia.
[ d. Providers shall develop a plan for supports that shall include at a minimum for each individual enrolled in one of the three DD Waivers:
(1) The individual's desired outcomes that describe what is important to and for the individual in observable terms;
(2) Support activities and support instructions that are inclusive of skill-building as may be required by the service provided and that are designed to assist in achieving the individual's desired outcomes;
(3) The services to be rendered and the schedule for such services to accomplish the desired outcomes and support activities, a timetable for the accomplishment of the individual's desired outcomes and support activities, the estimated duration of the individual's need for services, and the provider staff responsible for overall coordination and integration of the services specified in the plan for supports; and
(4) Documentation regarding any restrictions on the freedoms of everyday life in accordance with 12VAC35-115, Regulations to Assure the Rights of Individuals Receiving Services from Providers Licensed, Funded, or Operated by the Department of Behavioral Health and Developmental Services and the requirements of 42 CFR 441.301. ]
[ d. e. ] Providers shall prepare and maintain unique person-centered [ progress note ] written documentation [ in the form of progress notes or supports checklist as defined by the service. These shall be ] in each individual's [ medical ] record about the individual's responses to [ services and rendered ] supports [ and specific circumstances that prevented provision of the scheduled service, should that occur ]. Such documentation shall be provided to DMAS or its designee upon request. Such documentation shall be written [ , signed, and dated ] on the [ date of service delivery. day the described supports were provided. Documentation that occurs after the date services were provided shall be dated with the date the documentation was completed and also include the date the services were provided within the body of the note. ] In instances when the individual does not communicate through words, the provider shall note his observations about the individual's condition and observable responses, if any, at the time of service delivery.
[ e. Examples of unacceptable f. Unacceptable ] person-centered progress [ note written documentation notes ] include:
(1) Standardized or formulaic notes;
(2) Notes copied from previous service dates and simply redated;
(3) Notes that are not signed and dated by staff who deliver the service, with the date services were rendered; and
(4) Person-centered progress [ note written documentation notes ] that [ does do ] not document the individual's unique opinions or observed responses to supports.
[ f. g. ] Providers shall maintain an attendance log or similar document that indicates the date services were rendered, type of services rendered, and number of hours or units provided (including specific timeframe [ for services with a unit of service shorter than one day ]) for each service type except for one-time services such as assistive technology service, environmental modifications service, transition service, individual and family caregiver training service, electronic home-based support service, services facilitation service, and personal emergency response system support service, where initial documentation to support claims shall suffice.
[ g. Providers shall develop a plan for supports that shall include at a minimum for each individual in its caseload:
(1) The individual's desired outcomes that describe what is important to and for the individual in observable terms;
(2) Support activities and support instructions that are inclusive of skill-building as may be required by the service provided and that are designed to assist in achieving the individual's desired outcomes;
(3) The services to be rendered and the schedule for such services to accomplish the desired outcomes and support activities, a timetable for the accomplishment of the individual's desired outcomes and support activities, the estimated duration of the individual's need for services, and the provider staff responsible for overall coordination and integration of the services specified in the plan for supports; and
(4) Documentation regarding any restrictions on the freedoms of everyday life in accordance with human rights regulations (12VAC35-115) and the requirements of 42 CFR 441.301.
11. 13. ] Agree to furnish information and record documentation on request and in the form requested to DMAS, DBHDS, the Attorney General of Virginia or his authorized representatives, federal personnel (e.g., Office of the Inspector General), and the State Medicaid Fraud Control Unit. The Commonwealth's right of access to provider premises and records shall survive any termination of the provider participation agreement.
[ 12. 14. ] Disclose, as requested by DMAS, all financial, beneficial, ownership, equity, surety, or other interests in any and all firms, corporations, partnerships, associations, business enterprises, joint ventures, agencies, institutions, or other legal entities providing any form of health care services to individuals enrolled in Medicaid.
[ 13. 15. ] Perform criminal history record checks for barrier crimes in accordance with applicable licensure requirements at §§ 37.2-416, 37.2-506, and [ 37.2-600 37.2-607 ] of the Code of Virginia, as applicable. If the individual enrolled in the waiver is a minor child, also perform a search of the VDSS Child Protective Services Central Registry. The provider shall not be compensated for services provided to the individual enrolled in the waiver effective on the date and afterwards that any of these records checks verifies that [ the provider has been convicted of barrier crime, as is applicable to the provider's license, or if the provider has a finding in the VDSS Child Protective Services Central Registry (if applicable). the staff person providing services was ineligible to do so pursuant to the applicable statute. ]
a. For consumer-directed (CD) services, the CD employee shall submit to a criminal history records check conducted by the [ DMAS designated ] fiscal employer agent [ within 30 days of employment ]. [ If the individual enrolled in the waiver is a minor child, the CD employee shall also submit to a search within the same 30 days of employment of the VDSS Child Protective Services Central Registry. The CD employee shall not be compensated for services provided to the waiver individual effective The CD employee shall be compensated for up to 30 days of employment while the background check is being processed or to ] the date on which [ the employer of record learned, or should have learned, that ] the [ record background ] check verifies that the CD employee has been convicted of [ a ] barrier [ crimes crime ] pursuant to § 37.2-416 of the Code of Virginia or if the CD employee has a founded complaint confirmed by the VDSS Child Protective Services Central Registry (if applicable) [ , whichever comes first ].
[ b. The DMAS-designated fiscal employer agent shall require the CD employee to notify the employer of record of all convictions occurring subsequent to the initial record check. CD employees who refuse to consent to criminal background checks and VDSS Child Protective Services Central Registry checks shall not be eligible for Medicaid reimbursement.
c. b. ] The CD employer of record shall require CD employees to notify the employer of record of all convictions occurring subsequent to the initial record check. CD employees who refuse to consent to criminal background checks and VDSS Child Protective Services registry checks shall not be eligible for Medicaid reimbursement.
[ 14. 16. ] Report suspected abuse or neglect immediately at first knowledge to the local Department for Aging and Rehabilitative Services, adult protective services agency or the local department of social services, child protective services agency; to DMAS or its designee; and to the DBHDS [ Offices of Licensing and Office of ] Human Rights, if applicable pursuant to §§ 63.2-1509 and 63.2-1606 of the Code of Virginia when the participating provider knows or suspects that an individual receiving home and community-based waiver services is being abused, neglected, or exploited.
[ 15. 17. ] Refrain from engaging in any type of direct marketing activities to Medicaid individuals or their families/caregivers. "Direct marketing" means (i) conducting directly or indirectly door-to-door, telephonic, or other cold call marketing of services at residences and provider sites; (ii) mailing directly; (iii) paying finder's fees; (iv) offering financial incentives, rewards, gifts, or special opportunities to eligible individuals and the individual's family/caregivers, as appropriate, as inducements to use the provider's services; (v) continuous, periodic marketing activities to the same prospective individual and the individual's family/caregiver, for example, monthly, quarterly, or annual giveaways, as inducements to use the provider's services; or (vi) engaging in marketing activities that offer potential customers rebates or discounts in conjunction with the use of the provider's services or other benefits as a means of influencing the individual and the individual's family/caregivers use of the provider's services.
[ 16. 18. ] Providers shall ensure that staff providing waiver services read and write English to the degree required to create and maintain the required documentation.
[ 19. Providers shall document and maintain written semiannual supervision notes for each DSP and supervisor of DSPs that are signed and dated by the supervisor. Additionally,
a. For DBHDS-licensed entities, the provider shall provide ongoing supervision of all DSP staff, including those employees such as supervisors, that are directly involved with individuals being served, consistent with the requirements of 12VAC35-105.
b. For providers who are licensed by VDH or have accreditation from a CMS-recognized organization to be a personal care or respite care provider, they shall provide ongoing supervision of companion or DSP staff consistent with those regulatory requirements.
20. Providers shall ensure that all employees or contractors without pertinent or medical clinical licenses who will be responsible for medication administration demonstrate competency of this set of skills under direct observation prior to performing this task without direct supervision.
21. DBHDS-licensed providers shall ensure all employees or contractors who will be responsible for performing de-escalation or behavioral interventions demonstrate competency of this set of skills under direct observation prior to performing these tasks with any individual service recipient. ]
B. Providers of services under any of the DD Waivers shall not be parents or guardians of individuals enrolled in the waiver who are minor children, or [ in the case of an adult enrolled in the waiver, ] the adult individual's spouse. Payment shall not be made for services furnished by other family members who are living under the same roof as the individual receiving services unless there is objective, written documentation, as defined in this subsection, as to why there are no other providers available to provide the care. Such other family members, if approved to provide services for the purpose of receiving Medicaid reimbursement, shall meet the same provider requirements as all other licensed providers. "Objective, written documentation" means documentation that demonstrates there are no persons available to provide supports to the individual other than the unpaid family/caregiver who lives in the home with the individual. Examples of such documentation may be (i) copies of advertisements showing efforts to hire; (ii) copies of interview notes; (iii) documentation indicating high turnover in consumer-directed assistants who provide, via the consumer-directed model of services, personal assistance services, companion services, respite services, or any combination of these three services; (iv) documentation supporting special medical or behavioral needs; or (v) documentation indicating that language is a factor in service delivery. [ The service provider shall provide such documentation as is necessary or requested by DBDHS for service authorization. ]
C. Providers shall not be reimbursed while the individual enrolled in a waiver is receiving inpatient services in either an acute care hospital, [ psychiatric hospital, ] nursing facility, rehabilitation facility, ICF/IID, or any other type of facility. [ Providers shall not be reimbursed while the individual enrolled in a waiver is subject to an Emergency Custody Order (ECO) or Temporary Detention Order (TDO). ]
D. Providers with a history of noncompliance, which may include [ (i) ] multiple records with citations of failure to comply with regulations [ or; (ii) ] multiple citations related to health and welfare for one [ service support ] plan [ ; or (iii) citation by either DMAS or DBHDS in key identified areas ], resulting in a corrective action plan or citation [ by either DMAS or DBHDS in key identified areas ] will be required to undergo mandatory training and technical assistance in the specific areas of noncompliance [ as part of a corrective action plan ]. These areas of noncompliance may include health, safety, or failure to address the identified needs of the individual. Failure to [ complete the mandatory training or identified technical assistance may comply with any areas in the corrective action plan shall ] result in referral to DMAS Program Integrity [ or and initiation of proceedings related to ] termination of the provider Medicaid participation agreement.
12VAC30-122-130. Provider termination.
A. Except as otherwise provided by applicable federal or state law, the Medicaid provider agreement may be terminated by DMAS (i) pursuant to § 32.1-325 of the Code of Virginia, (ii) as may be required by federal law for federal financial participation, and (iii) in accordance with the provider participation agreement, including termination at will on 30 days written notice. The agreement may be terminated if DMAS determines that the provider poses a threat to the health, safety, or welfare of any individual enrolled in a DMAS administered program. DMAS may also terminate a provider's participation agreement if the provider does not fulfill its obligations as described in the provider participation agreement. Such provider agreement terminations shall be in accordance with § 32.1-325 of the Code of Virginia, 12VAC30-10-690, and Part XII (12VAC30-20-500 et seq.) of 12VAC30-20. Termination precludes further payment by DMAS for services provided for individuals subsequent to the date specified in the termination notice.
B. A provider who has been convicted of a felony, or who has otherwise pled guilty to a felony, in Virginia or in any other [ of the 50 states state ], the District of Columbia, or the United States territories shall, within 30 days of such conviction, notify DMAS of this conviction and relinquish his provider agreement. Such provider agreement terminations shall be effective immediately and conform to § 32.1-325 of the Code of Virginia and 12VAC30-10-690. Providers shall not be reimbursed for services that may be rendered between the conviction of a felony and the provider's notification to DMAS of the conviction.
C. A participating provider may voluntarily terminate his participation with DMAS by providing 30 days written notification.
12VAC30-122-140. Provider confidentiality; change of ownership; completion of assessment instruments.
A. Pursuant to subpart F of 42 CFR Part 431, 12VAC30-20-90, and any other applicable federal or state law or regulation, all providers shall hold confidential and use for DMAS or DBHDS authorized purposes only all medical assistance information regarding individuals served. A provider shall disclose information in his possession only when the information is used in conjunction with a claim for health benefits or the data are necessary for purposes directly related to the administration of the State Plan for Medical Assistance and related waivers.
B. When ownership of the provider changes, the provider shall notify DMAS pursuant to 42 CFR 420.206.
C. For ICF/IID facilities covered by § 1616(e) of the Social Security Act in which respite care as a home and community-based waiver service will be provided, the facilities shall be in compliance with applicable regulatory standards.
D. Providers shall make available, as may be requested, specific, relevant information about the individual enrolled in the waiver.
12VAC30-122-150. Requirements for consumer-directed model of service delivery.
A. Criteria for consumer-directed model of service delivery.
1. The [ DD FIS and CL ] Waivers have three services that may be provided through a consumer-directed (CD) model: companion services, personal assistance services, and respite services. [ In addition to this chapter, consumer-direction shall comport with the requirements of § 54.1-2901 A 31 of the Code of Virginia. ]
2. Requirements for individual.
a. The individual or a person designated by the individual shall serve as the employer of record (EOR). If an individual is unable to direct his own care or is younger than 18 years of age, he [ may shall ] designate another person older than 18 years of age to serve as the [ employer of record (EOR) EOR ] on his behalf. [ If the individual is younger than 18 years of age, a legally responsible individual shall serve as the EOR. ]
b. The EOR shall be the employer in this service and shall be responsible for [ advertising recruiting ], interviewing, hiring, training, supervising, and firing CD [ employee ] assistants. Specific EOR duties include checking references of assistants, determining that assistants meet basic qualifications, training assistants, supervising the assistant's performance, and submitting and approving the assistant's timesheets to the [ DMAS designated ] fiscal employer agent on a consistent and timely basis.
c. The individual, the family/caregiver, or EOR, as appropriate, shall have [ an emergency a ] back-up plan in case the assistant does not show up for work.
d. Individuals choosing consumer-directed services may receive support from a CD services facilitator. Services facilitators shall assist the individual or his EOR, as appropriate, in accessing and receiving consumer-directed services. This function shall include providing the individual or EOR, as appropriate, with employer of record management training including a review and explanation of the employee management manual and routine and reassessment visits to monitor the CD services.
e. If an individual choosing consumer-directed services chooses not to receive support from a CD services facilitator, then [ the individual or the family/caregiver serving as another family member or caregiver other than ] the EOR shall perform all of the duties and meet all of the requirements of a CD services facilitator, including documentation requirements identified for services facilitation. However, the [ individual or family/caregiver family member or caregiver ] serving as the [ EOR services facilitator ] shall not be reimbursed by DMAS for performing these duties or meeting these requirements.
[ f. ] The individual's support coordinator/case manager may also function as the [ paid ] services facilitator.
12VAC30-122-160. Voluntary or involuntary disenrollment of consumer-directed services.
Either voluntary or involuntary disenrollment of the consumer-directed (CD) model of personal assistance, companion, or respite services may occur. In either voluntary or involuntary disenrollment, the individual enrolled in the waiver shall be permitted to select an agency from which to continue to receive his personal assistance services, companion services, or respite services. If the individual either fails to select an agency or refuses to do so, then personal [ care assistance ] services, companion services, or respite services, as appropriate, will be discontinued.
1. An individual who has chosen consumer direction may choose, at any time, to change to the agency-directed model as long as he continues to qualify for the specific services. The services facilitator or support coordinator shall assist the individual with the change of services from consumer-directed to agency-directed.
2. The services facilitator or support coordinator, as appropriate, shall initiate involuntary disenrollment from consumer direction of an individual enrolled in the waiver when any of the following conditions occur:
a. The health, safety, or welfare of the individual enrolled in the waiver is at risk;
b. The individual or EOR demonstrates consistent inability to hire and retain a CD [ personal ] assistant; or
c. The individual or EOR, as appropriate, is consistently unable to manage the CD [ personal ] assistant, as may be demonstrated by a pattern of serious discrepancies with timesheets.
[ d. ] If the individual does not choose a services facilitator and [ the individual/family a family member, other ] caregiver [ , or the support coordinator ] is not willing or able to assume the services facilitation duties, then the support coordinator shall notify DMAS or its designated service authorization contractor and the consumer-directed services shall be discontinued.
3. Prior to involuntary disenrollment, the services facilitator or support coordinator, as appropriate, shall:
a. Verify that essential training has been provided to the EOR to improve the problem condition or conditions;
b. Document in the individual's record the conditions creating the necessity for the involuntary disenrollment and actions taken by the services facilitator or support coordinator, as appropriate;
c. Discuss with the individual and the EOR, if the individual is not the EOR, the [ agency-direction agency-directed ] option that is available and the actions needed to arrange for such services while providing a list of potential providers;
d. Provide written notice to the individual and EOR, if the individual is not the EOR, of the action, the reasons for the action, and the right of the individual to appeal, pursuant to 12VAC30-110, such involuntary termination of consumer-direction. Except in emergency situations in which the health or safety of the individual is at serious risk, such notice shall be given at least 10 business days prior to the effective date of the termination of consumer-direction. In cases of an emergency situation, notice of the right to appeal shall be given to the individual but the requirement to provide notice at least 10 business days in advance shall not apply; and
e. If the services facilitator initiates the involuntary disenrollment from consumer-direction, inform the support coordinator of such action and the reasons for the action.
[ 4. Refer to 12VAC30-122-340, 12VAC30-122-460 and 12VAC30-122-490 for further requirements and limitations for companion services, personal assistance services, and respite services. ]
12VAC30-122-170. Fiscal employer/agent requirements.
A. Pursuant to a duly negotiated contract or interagency agreement, the [ DMAS designated ] fiscal employer/agent shall be reimbursed by DMAS to perform certain employer functions, including payroll and bookkeeping functions, on behalf of [ employer the EOR ] or individual who is receiving consumer-directed personal assistance services, companion services, and respite services. "Fiscal employer/agent" means a state agency or other entity as determined by DMAS to meet the requirements of 42 CFR 441.484 and the Virginia Public Procurement Act (Chapter 43 (§ 2.2-4300 et seq.) of Title 2.2 of the Code of Virginia) that performs an employer's salary payment and tax reporting functions for assistants employed for consumer-directed services.
B. The [ DMAS designated ] fiscal employer/agent shall be responsible for administering payroll services on behalf of the individual enrolled in the waiver [ including:. ]
[ 1. Collecting and maintaining citizenship and alien status employment eligibility information required by the U.S. Department of Homeland Security;
2. Submitting requests for criminal record checks within 15 calendar days of the assistant's employment on behalf of the individual or family/caregiver, as appropriate, and reporting results of such checks to the individual or family/caregiver, as appropriate;
3. Securing all necessary Internal Revenue Service authorizations and approvals in accordance with state and federal tax requirements;
4. Deducting and filing state and federal income and employment taxes and other withholdings;
5. Verifying that assistants' or companions' submitted timesheets do not exceed the maximum hours prior authorized for individuals enrolled in the waiver;
6. Processing timesheets for payment;
7. Making all deposits of income taxes, Federal Insurance Contributions Act, and other withholdings according to state and federal requirements; and
8. Distributing biweekly payroll checks to individuals' companions and assistants.
C. All timesheet discrepancies shall be reported promptly upon their identification to DMAS for investigation and resolution.
D. The fiscal employer/agent shall maintain records and information as required by DMAS and state and federal laws and regulations and make such records available upon request by DMAS in the needed format.
E. The fiscal employer/agent shall establish and operate a customer service center to respond to payroll and related inquiries by individuals and their assistants or companions.
F. The fiscal employer/agent shall maintain confidentiality of all Medicaid information pursuant to the Health Insurance Portability and Accountability Act (42 USC § 1320d et seq.), federal and state Medicaid requirements, and DMAS requirements. Should any breaches of confidential information occur, the fiscal/employer agent shall assume all liabilities under both state and federal law. ]
12VAC30-122-180. Orientation testing; professional competency requirements; advanced competency requirements.
A. Orientation training and testing for [ DBHDS licensed ] providers of agency-directed personal assistance services, agency-directed companion services, agency-directed respite services, center-based crisis [ support, community-based crisis services, supports, ] crisis support services, community engagement services, community coaching services, group day services, group home residential services, independent living support services, [ individual and group supported employment, ] in-home support services, sponsored residential services, supported living residential services, and workplace assistance.
1. Providers shall ensure that direct support professionals (DSPs) and DSP supervisors providing services to individuals with developmental disabilities receive or have received training on the following knowledge, skills, and abilities [ consistent with DBHDS licensing requirements ]. These knowledge, skills, and abilities are addressed in the DMAS-approved orientation training.
a. The characteristics of developmental disabilities and Virginia's DD Waivers;
b. Person-centeredness, positive behavioral supports, and effective communication;
c. Identified potential health risks of individuals with developmental disabilities and the appropriate interventions; [ and ]
d. [ Community integration and social inclusion; and
e. ] Best practices in the support of individuals with developmental disabilities.
2. Providers shall ensure that DSPs and DSP supervisors pass or have passed, with a minimum score of 80%, a DMAS-approved objective, standardized test of knowledge, skills, and abilities demonstrating knowledge of the topics referenced in subdivision 1 of this subsection prior to providing direct, reimbursable services. Other qualified staff who have passed the knowledge-based test shall work alongside any DSP or supervisor who has not yet passed the test.
3. [ A For DSPs, a ] copy of the DSP orientation test completed by the DSP with the test score will be filed in the personnel file along with the assurance document with DSP and [ supervisor or ] designee signatures and shall be subject to review by DBHDS for licensing compliance purposes [ , as applicable, ] and by DMAS for quality management reviews, utilization reviews, and financial audit purposes. [ For supervisors, a certificate of completion from a DMAS approved supervisory training shall be retained in place of a copy of the written test. ]
[ B. Orientation training and testing for non-DBHDS licensed providers.
1. Providers of agency directed personal assistance, companion, and respite services shall ensure that DSPs and DSP supervisors providing services to individuals with developmental disabilities receive or have received training on the following:
a. The characteristics of developmental disabilities and Virginia's DD Waivers;
b. Person-centeredness, positive behavioral supports, and effective communication;
c. Identified potential health risks of individuals with developmental disabilities and the appropriate interventions; and
d. Best practices in the support of individuals with developmental disabilities.
2. Providers shall ensure that DSPs and DSP supervisors pass or have passed, with a minimum score of 80%, a DMAS-approved objective, standardized test of knowledge, skills, and abilities demonstrating knowledge of topics referenced in subdivision 1 of this subsection prior to providing direct, reimbursable services. Other qualified staff who have passed the knowledge-based test shall work alongside the DSP or DSP supervisor who has not yet passed the test.
3. A copy of the DSP orientation test completed by the DSP with the test score will be filed in the personnel file along with the assurance document with DSP and designee signatures and shall be subject to review by DBHDS for licensing compliance purposes and by DMAS for quality management reviews, utilization reviews, and financial audit purposes.
C. B. ] The following [ DBHDS licensed ] waiver providers shall ensure that [ new ] DSPs [ or and ] DSP supervisors, including relief and contracted staff, complete [ the ] competency [ training observation ] and [ the competency ] checklist within 180 days from date of hire: agency-directed personal assistance service, agency-directed companion service, agency-directed respite service, center-based crisis support service, [ community-based crisis service, ] community engagement service, community coaching service, [ crisis support service, ] group day service, group home residential service, independent living service, [ individual and group supported employment, ] in-home support service, sponsored residential service, support living residential service, and workplace assistance service.
1. Evidence of completed core competency [ training observation ] and demonstrated proficiency, and documentation of assurances (DMAS Form P242a or P245a), shall be retained in the [ provider personnel ] record.
2. Such provider documentation shall be subject to review by DBHDS for licensing compliance purposes [ as applicable ] and by DMAS for quality management review, utilization reviews, and financial audit purposes.
3. The director of the provider organization or the director's designee shall complete the competencies checklist (DMAS Form P241a) for each DSP supervisor within 180 days from date of hire with annual updates thereafter.
4. Providers shall ensure that supervisors of DSPs complete the competencies checklist (DMAS Form P241a) for each DSP they supervise within 180 days of the DSP hire date and complete annual updates thereafter. [ For sponsored residential services, the date of hire can be the date that the sponsor begins providing service in the sponsored home setting. For all services listed in subsection B of this section, the health and safety related direct support skills contained in the competencies checklist will only be performed under direct supervision, including observations and guidance, of qualified staff until competence is observed and documented. ] Contracted and relief staff are also required to complete the competencies within 180 days from the first date of hire or original contract. The purpose of this checklist shall be to document the DSP's proficient mastery of the stated core competencies.
5. [ If upon review a DSP or DSP supervisor does not demonstrate proficiency in one or more competency areas, then within 180 days of this review the DSP or DSP supervisor shall review the training information, and orientation retesting shall be completed achieving a score of at least 80% documenting proficiency in the identified area or areas. DMAS shall not reimburse for those services provided by DSPs or DSP supervisors who have failed to pass the orientation test or demonstrate competencies as required. If at any time after the initial 180 days, a DSP or DSP Supervisor is found to be deficient in any competency area, the following actions must be taken to permit the continuation of billing by the agency related to the areas of the person's identified deficiencies. "Deficient" is defined as an established pattern of inability to demonstrate one or more competency skills.
a. Upon discovery of a staff person's inability to demonstrate proficiency, the provider has seven calendar days to begin remediation of the identified skills and document the issue and the actions taken by the agency to confirm proficiency. This initial seven-day process is considered a first episode of one or more identified deficiencies
b. If proficiency is not reconfirmed within seven days following discovery of a second episode, occurring within three months of the staff person's inability to demonstrate proficiency, the skills being remediated shall only be performed under direct supervision, observation, and guidance of qualified staff who document the provision of these supports in the person's record.
c. Once proficiency with these skills have been demonstrated, the provider shall maintain a signed confirmation that describes the actions taken and is completed by the DSP supervisor for DSPs and the agency director or designee for DSP supervisors and may resume billing for these related supports provided by the DSP or DSP supervisor from that date forward. ]
6. These DSP and DSP supervisor-specific checklists along with the annual updates shall be retained in the provider personnel records and shall be subject to review by DBHDS for licensing compliance purposes [ as applicable ] and by DMAS for quality management reviews, utilization reviews, and financial audit purposes.
[ D. Non-DBHDS licensed waiver providers shall ensure that new DSPs or DSP supervisors, including relief and contracted staff, complete the professional assurances within 180 days from date of hire for agency-directed personal assistance services, agency-directed companion services, and agency-directed respite services.
1. Evidence and documentation of assurances (DMAS Form P243a or P246a) shall be retained in the provider record
2. DSP supervisors shall maintain completed documentation of the online certificate from the DBHDS Learning Management System.
3. Such provider documentation shall be subject to review by DBHDS for licensing compliance purposes and by DMAS for quality management review, utilization reviews, and financial audit purposes. ]
[ E. C. ] Advanced core competency requirements for DSPs and DSP supervisors serving individuals with developmental disabilities with the most intensive needs, as [ identified as ] assigned to [ Level 6 or 7 (as referenced in 12VAC30-122-200) Tier 4 (described in 12VAC30-122-210) ], shall be as follows:
1. Providers shall ensure that DSPs and DSP supervisors supporting individuals identified as having the most intensive needs, as determined by [ assignment to Level 6 or 7 Tier 4 ], shall receive training that is developed or approved by a qualified professional in the areas of health, behavioral needs, autism, or all three, as defined by DMAS and based on the identified needs of the individuals supported.
2. DSPs and DSP supervisors supporting individuals with [ identified ] health support needs and [ assignment toLevel 6 or 7 at Tier 4 ] shall receive training in the area of medical supports and based on the identified needs of the individuals supported.
3. DSPs and DSP supervisors supporting individuals with [ identified ] behavioral support needs and [ assignment to Level 6 or 7 at Tier 4 ] shall receive training in the area of behavioral supports and based on the identified needs of the individuals supported.
4. DSPs and DSP supervisors supporting individuals with autism and [ assignment to Level 6 or 7 at Tier 4 ] shall receive training on characteristics of autism and based on the identified needs of the individuals supported.
5. DSPs and DSP supervisors supporting individuals at other support levels but who are receiving a customized rate shall receive training in the appropriate areas related to the needs of the individual.
6. Evidence of training completed by DSPs and DSP supervisors shall be retained in the personnel file and be subject to review by DBHDS for licensing compliance and by DMAS for quality management review, utilization review, and financial audit purposes.
7. The director of the provider agency or designee shall complete the appropriate advanced core competencies checklists (DMAS Forms P240a, P244a, and P201) specific to the needs [ and level ] of the individuals supported by each DSP supervisor within 180 days of the date of hire [ , or within 180 days of the first admission of a person with related needs or identification of the individual's level, ] with completed annual updates thereafter. The checklists shall be retained in the personnel file and be subject to review by DBHDS for licensing compliance and by DMAS for quality management review, utilization review, and financial audit purposes.
8. Providers shall ensure that DSP supervisors complete the advanced core competencies checklists (DMAS Forms P240a, P244a, and P201) specific to the needs [ and service levels ] of the individuals supported for each DSP that the DSP supervisors supervise within 180 days of hiring the DSP [ or within 180 days of initiating services to an individual with related support needs ], with annual competency checklist updates thereafter. These checklists shall be used to document proficient mastery of the stated core competencies.
9. [ If upon review a DSP or DSP supervisor does not demonstrate proficiency in one or more advanced competency areas, then within 180 days of such review the DSP or DSP supervisor shall review the training information, and orientation retesting shall be completed as appropriate with a score of at least 80% demonstrating proficiency in the identified area. DMAS shall not reimburse for those services provided by DSPs or DSP supervisors who have failed to demonstrate competencies as required. If at any time after the initial 180 days, a DSP or DSP supervisor is found to be deficient in any competency area, the following actions must be taken to permit the continuation of billing by the agency related to the areas of the person's identified deficiencies. "Deficient" is defined as an established pattern of inability to demonstrate one or more competency skills.
a. Upon discovery of a staff person's inability to demonstrate proficiency, the provider has seven calendar days to begin remediation of the identified skills and document the issue and the actions taken by the agency to confirm proficiency.
b. If proficiency is not reconfirmed within seven days following discovery of a second episode occurring within three months of the staff person's inability to demonstrate proficiency, the skills being remediated shall only be performed under direct supervision, observation, and guidance of qualified staff who document the provision of these supports in the person's record.
c. Once proficiency with these skills have been demonstrated, the provider shall maintain a signed confirmation that describes the actions taken and is completed by the DSP supervisor for DSPs and by the agency director or designee for DSP supervisors. The provider may resume billing for these related supports provided by the DSP or DSP supervisor from that date forward. ]
10. Providers shall retain these checklists in the personnel files that are subject to review by DBHDS for licensing compliance and by DMAS for quality management review, utilization review, and financial audit purposes. Continued knowledge of the advanced core competencies by DSP supervisors shall be confirmed in accordance with subdivisions 6 and 7 of this subsection.
12VAC30-122-190. Individual support plan; plans for supports; reevaluation of service need.
A. Every individual who has been approved to receive FIS, CL, or BI waiver services shall have a unique person-centered individual support plan (ISP) that sets out his unique, specific needs and the services designed to meet those needs.
1. The ISP shall be collaboratively developed at the onset of waiver services and redeveloped, at a minimum, annually by the support coordinator with the individual and the individual's family/caregiver, as appropriate, other providers, consultants as may be needed, and other interested parties at the individual's discretion.
2. The support coordinator shall be responsible for continuously monitoring the appropriateness of the individual's services and making timely revisions to the ISP as indicated by the changing needs of the individual.
3. Any modification to the amount or type of services in the ISP shall be service authorized by DMAS or its designee.
4. The support coordinator shall monitor the providers' plans for supports to ensure that all providers are working toward the desired outcomes with the individuals supported.
5. Support coordinators shall be required to conduct and document evidence of monthly onsite visits for all individuals enrolled in the DD Waivers who are residing in VDSS-licensed assisted living facilities or approved adult foster care homes.
6. Support coordinators shall conduct and document a minimum of quarterly [ face-to-face ] visits to all other individuals with at least one visit annually occurring in the home.
7. All requests for [ increased increases in DD ] waiver services [ for individuals enrolled in one of the DD Waivers ] shall be reviewed by the support coordinator [ to. The support coordinator shall ] ensure that the [ individual's health, safety, and welfare in the community request ] is [ dependent based ] on the [ finding that the individual demonstrates a individual's demonstrated ] need for the [ increased ] service, [ based on as documented by ] appropriate assessment criteria and a written plan for supports, and that those services [ are necessary to promote the individual's health, safety, and welfare in the community and ] can be safely and cost effectively provided in the community.
8. [ Individuals Support coordinators shall provide an individual ] and the family/caregiver [ shall be provided, as appropriate, ] with a copy of the individual's ISP.
B. Providers shall develop and keep updated, to include changing needs, a plan for supports for every individual supported. The contents of the plan for supports shall at a minimum contain the items specified in 12VAC30-122-120 A 10 [ f g ]. Services that are exempt from provider plans for supports requirements can be found in each service's specific regulation section.
C. Reevaluation of service need.
1. At a minimum, the support coordinator shall review the ISP [ at least ] quarterly to determine whether the individual's desired outcomes and support activities are being met and whether any modifications to the ISP are necessary. The results of such reviews shall be documented, signed, and dated in the individual's record even if no change occurred during the review period. This documentation shall be provided to DMAS and DBHDS upon request.
2. Components of annual person-centered plan review.
a. The support coordinator shall complete a reassessment annually, at a minimum, in coordination with the individual and the individual's family/caregiver, as appropriate, providers, and others as desired by the individual. The reassessment shall be signed and dated by the support coordinator and shall include an update of the level of care [ (VIDES) ] and personal profile, risk assessment, and any other appropriate assessment information. "Risk assessment" means an assessment used to determine areas of high risk of danger to the individual or others based on the individual's serious medical or behavioral factors and shall be used to plan risk mitigating supports for the individual in the individual support plan.
[ b. ] The ISP shall be revised as appropriate for consistency with this reassessment. If this annual level of care reassessment demonstrates that the individual no longer meets waiver requirements, the support coordinator shall inform DMAS and DBHDS that the individual must be terminated from waiver services.
[ b. c. ] A medical examination shall be completed in accordance with [ 12VAC35-105-740 12VAC30-122-180 and, for adults, as needed thereafter ].
[ c. d. ] Medical examinations and screenings for children ages birth to 21 years shall be completed according to the recommended frequency and periodicity of the EPSDT program (42 CFR 440.40 and 12VAC30-50-130).
[ d. e. ] A new psychological or other diagnostic evaluation shall be required whenever the individual's functioning has undergone significant change, such as deterioration of abilities that is expected to last longer than 30 days, and is no longer reflective of the past evaluation. "Significant change" means a change in an individual's condition that is expected to last longer than 30 calendar days but shall not include short-term changes that resolve with or without intervention, a short-term acute illness or episodic event, or a well-established, predictive, cyclical pattern of clinical signs and symptoms associated with a previously diagnosed condition where an appropriate course of treatment is in progress.
[ f. ] The [ psychological or other diagnostic ] evaluation shall be completed by a qualified examiner, as defined in this subdivision, and reflect the current diagnosis, adaptive level of functioning, and presence of a functional delay that arose during the developmental period. "Qualified examiner" means a credentialed professional, for example a licensed physician, licensed psychologist, or licensed therapist, who is practicing pursuant to the requirements and limits of his license.
[ e. g. ] The individual shall be allowed to select other entities, either persons or organizations, at his discretion to participate in the annual review of his person-centered plan.
12VAC30-122-200. Supports Intensity Scale® requirements; Virginia Supplemental Questions; levels of support; supports packages.
A. The Supports Intensity Scale (SIS®) requirements.
1. The SIS® is an assessment tool that identifies the practical supports required by individuals to live successfully in their communities. DBHDS shall use the SIS® [ Child Children's Version™ (SIS-C™) ] for individuals who are five years through 15 years of age. DBHDS shall use the SIS® Adult [ Version® (SIS-A®) ] for individuals who are 16 [ to 72 ] years of age [ and older ]. Individuals who are younger than five years of age shall be assessed using [ either the SIS® or an age-appropriate alternative instrument, such as the Early Learning Assessment Profile, as approved by DBHDS. an age-appropriate standardized living skills assessment. ]
2. A SIS® assessment and [ the current version of ] the Virginia Supplemental Questions (VSQ), as appropriate, shall be completed with the individual and other appropriate parties who have knowledge of the individual's circumstances and needs for support:
a. [ At least every four years for those individuals who are 22 years of age and older.
b. ] At least every three years for those individuals who are 16 years of age [ and older through 21 years of age ].
[ b. c. ] Every two years for individuals five years through 15 years of age when the individual is using a tiered service, such as group home residential, sponsored residential, supported living residential, group day, or community engagement. Another developmentally appropriate standardized living skills assessment approved by DBHDS, such as the Brigance Inventory, Vineland, or Choosing Outcomes and Accommodations for Children shall be completed every two years for service planning purposes for those in this age grouping who do not receive a SIS® assessment.
[ d. For a, b, and c of this subdivision A 2, when the individual's support needs have been deemed to have changed significantly for a sustained period of at least six months. ]
[ c. e. ] For children younger than five years of age, an alternative industry assessment instrument approved by DBHDS, such as the Early Learning Assessment Profile, shall be completed every two years for service planning purposes.
[ d. When the individual's support needs change significantly for a sustained period of at least six months. ]
3. The SIS® shall be used in conjunction with VSQ, the person-centered planning process, [ VIDES, ] and other assessment information to develop each individual's ISP. The SIS® shall be used to assess individuals' patterns and intensity of needed supports across life activities such as (i) home [ and community ] living activities; (ii) [ community living activities school activities for children ]; (iii) lifelong learning [ and employment activities for adults; (iv) employment; (v) ] health [ , and ] safety [ activities ], social activities, and [ self-advocacy advocacy activities ]; [ (vi) (v) exceptional ] medical and behavioral support needs; and [ (vii) (vi) ] what is important to and important for individuals who are enrolled in a waiver.
4. [ The sum of (i) the standard scale scores Scores ] from [ SIS® Adult Parts SIS-A® and SIS-C™ Section 1 (Exceptional Medical Needs, Exceptional Behavioral Needs), Section 2 Subsections ] A, B, and E [ (ABE) in Section 1; (ii) scale scores associated with SIS® Section 3 Part A and B; and (iii) and ] responses to Supplemental Questions shall be used to assign levels of supports [ (Levels 1 through 7, as defined in 12VAC30-122-250) ] to each [ adult ] individual [ , as follows:. ]
|
[ Seven Levels of Supports
|
SIS® Sum Scales
Parts ABE
|
Section 3 Part A
Medical Support
|
Section 3 Part B
Behavior Support
|
|
|
Least support needs (Level 1)
|
0 to 22
|
0 to 6
|
0 to 6
|
|
|
Modest or moderate support needs (Level 2)
|
23 to 30
|
0 to 6
|
0 to 6
|
|
|
Least/moderate support needs with some behavioral needs (Level 3)
|
0 to 30
|
0 to 6
|
7 to 10
|
|
|
Moderate to high support needs (Level 4)
|
31 to 36
|
0 to 6
|
7 to 10
|
|
|
High to maximum support needs (Level 5)
|
37 to 52
|
0 to 6
|
0 to 10
|
|
|
Extraordinary medical support needs (Level 6)
|
Any
|
7 to 32 or verified extraordinary medical risk
|
0 to 10
|
|
|
Extraordinary behavioral support needs (Level 7)
|
Any
|
Any
|
11 to 26 or verified danger to others or extreme self-injury risk ]
|
|
5. The SIS® shall be administered and analyzed by qualified, trained interviewers designated by DBHDS.
B. The [ current version of the ] Virginia Supplemental Questions (VSQ version [ 10/26/2014 10/2017 ] ) shall also be used to identify individuals who have unique needs falling outside of the needs identifiable by the SIS® instrument. The VSQ shall also be administered and analyzed by the same qualified, trained interviewers designated by DBHDS.
1. The Virginia Supplemental Questions shall address these topics:
a. Severe medical risk;
b. Severe community safety risk for people with a related legal conviction;
c. Severe community safety risk for people with no related legal conviction; [ and ]
d. Severe risk of harm to self [ .; and ]
[ e. Fall risk. ]
2. [ Each Supplemental Question shall have five individual items labeled A through E. A 'yes' response to any of these items shall require a review of the individual's record for verification. Specified affirmative responses to the items in subdivisions B 1 a through B 1 d of this section shall require a review of the individual's record for verification. ] After such review, the individual may or may not be assigned to Level 6 ([ exceptional ] medical) or Level 7 ([ exceptional ] behavioral).
C. The results of the SIS®, Virginia Supplemental Questions, and, as needed, a document review verification process shall determine the individual's required level of supports. The results of the SIS®, other assessment information, and the person-centered planning process shall establish the basis for the individual support plan.
D. Establishment of supports packages, which means [ a profile of the mix and extent of services anticipated to be needed by individuals with similar levels, needs, and abilities. (Reserved.) a set of assumptions regarding the types and amounts of supports that an individual needs to be adequately supported in the community. It is a model that reflect reasonable services levels based on common expectations for persons who share similar characteristics. ]
12VAC30-122-210. Payment for covered services (tiers).
A. Waiver services shall be reimbursed according to the agency fee schedule unless otherwise specified in this section. Units of service and service limits are set out in the section for each service. There shall be no designated formal schedule for annual cost of living or other adjustments and any adjustments to provider rates shall be subject to available funding and approval by the General Assembly. Rate methodologies shall also be subject to the approval of the Centers for Medicare and Medicaid services.
1. [ All Those ] services [ shall that ] have a Northern Virginia and Rest of State rate [ and ] shall be paid based on the individual's place of residence.
2. The following services shall have variable rates based on size:
a. Group homes rates shall vary based on licensed bed size;
b. Group supported employment rates shall vary by group size; and
c. In-home residential rates shall vary by the number of individuals being served in the same home by one direct service professional.
3. There shall be up to four tiers of reimbursement for these services: community engagement, group day support, group home, independent living, sponsored residential support, and supported living residential. Four reimbursement tiers for [ an individual providers ] shall be based on seven levels of support (as detailed in 12VAC30-122-200) from resultant scores of the SIS®, the responses to the Virginia Supplemental Questions, and, as needed, a document review verification process. The DMAS designee shall verify the scores and levels of the individuals, as appropriate.
a. Levels of supports [ : range from Level 1 to Level 7 based on the needs of the individuals. ]
[ (1) Level 1 shall mean low support needs;
(2) Level 2 shall mean low to moderate support needs;
(3) Level 3 shall mean moderate support needs plus some behavior challenges;
(4) Level 4 shall mean moderate to high support needs;
(5) Level 5 shall mean maximum support needs;
(6) Level 6 shall mean significant support needs due to medical challenges, and;
(7) Level 7 shall mean significant support needs due to behavioral challenges. ]
b. Tiers of reimbursement:
(1) Tier 1 shall be used for individuals having Level 1 support needs.
(2) Tier 2 shall be used for individuals having Level 2 support needs.
(3) Tier 3 shall be used for individuals having either Level 3 or Level 4 support needs.
(4) Tier 4 shall be used for individuals having either Level 5, Level 6, or Level 7 support needs.
[ For the purposes of this subdivision A 3, "tiers of reimbursement" means tiers that are tied to an individual's level of support so that providers are reimbursed for services provided to individuals consistent with that level of support. ]
4. Individual-specific support needs, such as the [ extraordinary intense and significant ] medical or behavioral supports needs, may warrant customized rates for additional supports as described in this section, in the following service settings: community coaching service, group day service, in-home support service, group home residential service, sponsored residential service, and supported living residential service.
a. In these cases, providers [ and support coordinators ] shall submit to the DMAS designee a [ written ] request for a customized reimbursement rate exceeding the reimbursement rate for the assessed level of support of the individual. The request shall include [ , for example, ] contact information [ , and a detailed explanation of the basis for the request, such as the individual's support needs, ] increased staffing supports needed for the individual, the types of service for which the request is made, increased program oversight needed for the individual, the individual's behavior or medical support needs, or the individual's need for staff with certain qualifications.
b. The request shall be reviewed by a team of clinical and administrative personnel from the DMAS designee to determine that the documentation substantiates the intense needs of the individual, whether medical, behavioral, or both, and that the provider has employed staff with higher qualifications (e.g., direct support professionals with four-year degrees) or increased the ratio of staff-to-individual support of one staff person to one individual (1:1) or, in the case of services already required to be provided at a 1:1 ratio, a two staff persons to one individual (2:1) ratio.
c. The customized rate methodology shall modify the existing rate methodology assumptions for the following components in the existing rate methodologies: additional hours related to increased or specialized staffing supports and program costs.
d. Customized reimbursement rate determinations may be appealed pursuant to 12VAC30-20-500 et seq.
e. [ For those individuals approved for customized rates, providers shall submit to the DMAS designee at least annually a request if seeking continuation of the customized reimbursement rate. The request shall include the items specified in 12VAC30-122-210 A 4 a, as well as documentation of continued need for a reimbursement rate exceeding the reimbursement rate for the assessed level of support of the individual. ] The DMAS designee shall review [ on at least an annual basis in order for the affected provider to continue to receive the customized reimbursement rate the request in the manner specified in subdivision A 4 b of this section ]. After the review, adjustment determinations for the customized rate may be made. All such adjustment determinations may be appealed pursuant to 12VAC30-20-500 et seq.
B. Reimbursement rates for individual supported employment shall be the same as set by the Department for Aging and Rehabilitative Services for each individual supported employment provider agency.
C. Reimbursement for assistive technology (AT) service (12VAC30-122-270), electronic home-based support service (12VAC30-122-360), environmental modifications (EM) service (12VAC30-122-370), individual and family/caregiver training service (12VAC30-122-430), and transition service (12VAC30-122-560) shall be reimbursed based on approved costs subject to the following limits:
1. AT and EM approved costs for items and labor shall be reimbursed up to a per individual [ , per service ] maximum of $5,000 per calendar year across all home and community-based waivers.
2. Transition services approved costs shall be reimbursed up to a per individual maximum of $5,000 per lifetime across all home and community-based waivers.
3. Electronic home-based support approved costs shall be reimbursed up to a per individual maximum of $5,000 per [ calendar ISP ] year.
4. Individual and family/caregiver training approved costs shall be reimbursed up to a per individual maximum of $4,000 per [ calendar ISP ] year.
D. Duplication of services.
1. DMAS shall not duplicate the reimbursement for services that are required as a reasonable accommodation as a part of the Americans with Disabilities Act (42 USC § 12131 through 42 USC § 12165), the Rehabilitation Act of 1973 (29 USC § 701 et seq.), the Virginians with Disabilities Act (Title 51.5 (§ 51.5-1 et seq.) of the Code of Virginia), or any other applicable statute.
2. Payment for services under individual ISPs shall not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.
3. Payment for services under individual ISPs shall not be made for services that are duplicative of each other.
4. Payment for services shall only be provided for services as set out in an individual's ISP.
5. Payments that are determined to have been made contrary to these limitations shall be recovered by either DMAS or its designee.
12VAC30-122-220. Appeals.
A. Providers shall have the right to appeal actions taken by DMAS or its designee in accordance with § 32.1-325.1 of the Code of Virginia, the Virginia Administrative Process Act (Chapter 40 (§ 2.2-4000 et seq.) of Title 2.2 of the Code of Virginia), 12VAC30-10-1000, and 12VAC30-20-500 et seq.
B. Individuals shall have the right to appeal an action taken by DMAS or its designee in accordance with 12VAC30-110-10 through 12VAC30-110-370 and 42 CFR Part 431 subpart E. The individual shall be advised in writing of the action and of his right to appeal consistent with federal requirements and DMAS client appeals regulations (12VAC30-110-10 through 12VAC30-110-370).
12VAC30-122-230. Utilization review and quality management review.
A. Quality management review shall be performed by DMAS or its designee. Utilization review of rendered services shall be conducted by DMAS or its designee.
B. DMAS staff shall conduct utilization review of individual-specific provider documentation, which shall be forwarded by providers upon DMAS or DBHDS request.
[ C. Utilization review requirements specific to services in the developmental disability waivers shall be as follows:
1. To apply to be reimbursed as a Medicaid provider, the required DBHDS license shall be either a conditional or full (either annual or triennial) license.
2. Providers with provisional licenses issued by DBHDS shall not be reimbursed as Medicaid providers beginning 60 days from the issuance of the provisional license. Providers shall not request or receive authorizations or reauthorizations for services for new or currently supported individuals upon the issuance of the provisional license.
3. Reimbursement shall not be permitted to providers that fail to enter into a provider agreement with DMAS for a service prior to rendering that service or fail to maintain a current Medicaid Provider Enrollment Agreement. ]
12VAC30-122-240. Services covered in the Building Independence Waiver.
A. The Building Independence Waiver is designed to support individuals who reside in an integrated, independent living arrangement who can be supported through the provision of a minimal level of supports.
B. The services covered in the Building Independence Waiver for adults who are 18 years of age or older shall be:
1. Assistive technology service (12VAC30-122-270).
2. Benefits planning service [ (12VAC30-122-1070 - reserved) (12VAC30-122-280) ].
3. Center-based crisis support service (12VAC30-122-290).
4. Community-based crisis support service (12VAC30-122-300).
5. Community coaching service (12VAC30-122-310).
6. Community engagement service (12VAC30-122-320).
7. Community guide service (12VAC30-122-330 [ - reserved ]).
8. Crisis support service (12VAC30-122-350).
9. Electronic home-based support service (12VAC30-122-360).
10. Environmental modifications service (12VAC30-122-370).
11. Group day service (12VAC30-122-380).
12. Group and individual supported employment service (12VAC30-122-400).
13. Independent living support service (12VAC30-122-420).
14. [ Nonmedical Employment and community ] transportation service (12VAC30-122-440 [ - reserved ]).
15. Peer [ support mentor supports ] service (12VAC30-122-450 [ - reserved ]).
16. Personal emergency response system service (12VAC30-122-470).
17. Shared living [ support ] service (12VAC30-122-510).
18. Transition service (12VAC30-122-560).
C. Services shall be rendered in compliance with all of the requirements set out in 12VAC30-122-120 [ and the DD Waivers policy manual ]. Providers claims for reimbursement shall be supported by record documentation in accordance with federal requirements and DMAS regulatory requirements. Claims not supported by [ record ] documentation [ in the record ] may be subject to recovery of expenditures.
12VAC30-122-250. Services covered in the Community Living Waiver.
A. The Community Living Waiver is the developmental disabilities waiver designed particularly to support those individuals who require some form of a residential service 24 hours per day, seven days per week.
B. The services covered in the Community Living Waiver are:
1. Assistive technology service (12VAC30-122-270).
2. Benefits planning service (12VAC30-122-280 [ - reserved ]).
3. Center-based crisis support service (12VAC30-122-290).
4. Community-based crisis support service (12VAC30-122-300).
5. Community coaching service (12VAC30-122-310).
6. Community engagement service (12VAC30-122-320).
7. Community guide service (12VAC30-122-330 [ - reserved ]).
8. Companion service (12VAC30-122-340).
9. Crisis support service (12VAC30-122-350).
10. Electronic home-based support service (12VAC30-122-360).
11. Environmental modifications service (12VAC30-122-370).
12. Group day service (12VAC30-122-380).
13. Group home [ residential ] service (12VAC30-122-390).
14. Group and individual supported employment service (12VAC30-122-400).
15. In-home support service (12VAC30-122-410).
16. [ Nonmedical Employment and community ] transportation service (12VAC30-122-440 [ - reserved ]).
17. Peer [ support mentor supports ] service (12VAC30-122-450 [ - reserved ]).
18. Personal assistance service (12VAC30-122-460).
19. Personal emergency response system service (12VAC30-122-470).
20. Private duty nursing service (12VAC30-122-480).
21. Respite service (12VAC30-122-490).
22. Services facilitation service (12VAC30-122-500).
23. Shared living [ support ] service (12VAC30-122-510).
24. Skilled nursing service (12VAC30-122-520).
25. Sponsored residential service (12VAC30-122-530).
26. Supported living residential service (12VAC30-122-540).
27. Therapeutic consultation service (12VAC30-122-550).
28. Transition service (12VAC30-122-560).
29. Workplace assistance service (12VAC30-122-570).
C. Services shall be rendered in compliance with all of the requirements set out in 12VAC30-122-120. Providers claims for reimbursement shall be supported by [ record ] documentation [ in the record ] in accordance with federal requirements and DMAS regulatory requirements. Claims not supported by [ record ] documentation [ in the record ] may be subject to recovery of expenditures.
12VAC30-122-260. Services covered in the Family and Individual Support Waiver.
A. The Family and Individual Support Waiver is designed to support individuals who live with their families or in their own homes.
B. The services covered in the Family and Individual Support Waiver are:
1. Assistive technology service (12VAC30-122-270).
2. Benefits planning service (12VAC30-122-280 [ - reserved ]).
3. Center-based crisis support service (12VAC30-122-290).
4. Community-based crisis support service (12VAC30-122-300).
5. Community coaching service (12VAC30-122-310).
6. Community engagement service (12VAC30-122-320).
7. Community guide service (12VAC30-122-330 [ - reserved ]).
8. Companion service (12VAC30-122-340).
9. Crisis support service (12VAC30-122-350).
10. Electronic home-based support service (12VAC30-122-360).
11. Environmental modifications service (12VAC30-122-370).
12. Group day service (12VAC30-122-380).
13. Group and individual supported employment service (12VAC30-122-400).
14. In-home support service (12VAC30-122-410).
15. Individual and family/caregiver training service (12VAC30-122-430).
16. [ Nonmedical Employment and community ] transportation service (12VAC30-122-440 [ - reserved ]).
17. Peer [ support mentor supports ] service service (12VAC30-122-450 [ - reserved ]).
18. Personal assistance service (12VAC30-122-460).
19. Personal emergency response system service (12VAC30-122-470).
20. Private duty nursing service (12VAC30-122-480).
21. Respite service (12VAC30-122-490).
22. [ Services facilitation service (12VAC30-122-500)
23. ] Shared living [ support ] service (12VAC30-122-510).
[ 23. 24. ] Skilled nursing service (12VAC30-122-520).
[ 24. 25. ] Supported living residential service (12VAC30-122-540).
[ 25. 26. ] Therapeutic consultation service (12VAC30-122-550).
[ 26. 27. ] Transition service (12VAC30-122-560).
[ 27. 28. ] Workplace assistance service (12VAC30-122-570).
C. Services shall be rendered in compliance with all of the requirements set out in 12VAC30-122-120. Providers claims for reimbursement shall be supported by [ record ] documentation [ in the record ] in accordance with federal requirements and DMAS regulatory requirements. Claims not supported by [ record ] documentation [ in the record ] may be subject to recovery of expenditures.
12VAC30-122-270. Assistive technology service.
A. Service description. Assistive technology (AT) service shall entail the provision of specialized medical equipment and supplies including those devices, controls, or appliances specified in the individual support plan but that are not available under the State Plan for Medical Assistance that (i) enable individuals to increase their abilities to perform activities of daily living (ADLs); (ii) enable individuals to perceive, control, or communicate with [ the their ] environment [ in which they live ; (iii) actively participate in other waiver services that are part of their plan for supports ]; or [ (iii) (iv) ] are necessary for life support, including the ancillary supplies and equipment necessary to the proper functioning of such items. The AT service shall be covered in the FIS, CL, and BI waivers.
B. Criteria and allowable activities.
1. To qualify for the assistive technology service, the individual shall have a demonstrated need for equipment for remedial or direct medical benefit in the individual's primary home, primary vehicle, community activity setting, or day program to [ specifically improve the individual's personal functioning increase his ability to control his environment, support ISP outcomes as identified, and live safely and independently in the least restrictive community setting ]. The AT service shall be covered in the least expensive, most cost-effective manner and shall be limited to $5,000 per calendar year. There shall be no carryover of unspent funds from year to year. The [ covered ] equipment and activities shall include:
a. Specialized medical equipment and ancillary equipment;
b. Durable or nondurable medical equipment and supplies that are not otherwise available through the State Plan for Medical Assistance;
c. Adaptive devices, appliances, and controls that enable an individual to be independent in areas of personal care and ADLs; and
d. Equipment and devices that enable an individual to communicate more effectively.
2. Service requirements.
a. An independent professional consultation to determine the level of need that is not performed by the AT service provider shall be obtained from staff knowledgeable of that item for each AT service request prior to approval by DMAS or its designee. Equipment, supplies, or technology not available as durable medical equipment through the State Plan for Medical Assistance may be purchased and billed as the AT service as long as the request for such equipment, supplies, or technology is documented and justified in the individual's ISP, recommended by the support coordinator, service authorized by DMAS or its designee, and provided in the least expensive, most cost-effective manner possible.
b. If required, a rehabilitation engineer or certified rehabilitation specialist may be utilized if (i) the assistive technology will be initiated in combination with environmental modifications involving systems that are not designed to be compatible or (ii) an existing device must be modified or a specialized device must be designed and fabricated.
c. All AT service items to be covered shall meet applicable standards of manufacture, design, and installation.
d. The AT service provider shall obtain, install, and demonstrate, as necessary, that the service was authorized prior to submitting his claim to DMAS for reimbursement. The provider shall provide all warranties or guarantees from the AT manufacturer to the individual and family/caregiver, as appropriate.
C. Service units and limitations. The AT service shall be available to individuals who are receiving at least one other waiver service and may be provided in a residential or nonresidential setting described in subdivision B 1 of this section. The AT service shall be provided in the least expensive manner possible that will accomplish the modification required by the individual enrolled in the waiver.
1. The maximum funded expenditure per individual for all covered procedure codes (combined total of AT service items and labor related to these items) shall be $5,000 per calendar year and shall be completed within the calendar year. The service unit shall always be one for the total cost of all AT service being requested for a specific timeframe.
2. The AT service shall not be approved for purposes of convenience of the caregiver, [ or ] restraint of the individual, [ or ] recreation or leisure activities [ , or educational purposes ].
3. AT service providers shall not be the spouse, parent, or guardian of the individual enrolled in the waiver.
4. Requests for AT service via a DD Waiver shall be denied if AT service is available for children under EPSDT (12VAC30-50-130). No duplication of payment for the AT service shall be permitted between the waiver and services covered for adults that are reasonable accommodation requirements of the Americans with Disabilities Act (42 USC § 12101 et seq.), the Virginians with Disabilities Act (Title 51.5 (§ 51.5-1 et seq.) of the Code of Virginia), and the Rehabilitation Act (29 USC § 701 et seq.).
D. Provider qualifications and requirements.
1. Providers shall meet all of the requirements of 12VAC30-122-110 through 12VAC30-122-140.
2. AT service shall be provided by DMAS-enrolled durable medical equipment (DME) providers or DMAS-enrolled CSBs or BHAs with a signed, current waiver provider agreement with DMAS to provide the AT service. DME shall be provided in accordance with 12VAC30-50-165.
3. Independent assessments for the AT service shall be conducted by independent professional consultants. Independent, professional consultants include, for example, speech-language therapists, physical therapists, occupational therapists, physicians, behavioral therapists, certified rehabilitation specialists, or rehabilitation engineers.
4. Providers that supply AT service for an individual shall not perform assessment or consultation or write specifications. [ Providers of services shall not be spouses, parents, or guardians of the individual.
5. The AT service shall be delivered within the calendar year or within a year from the start date of the authorization. ]
[ 6. 5. ] The plan for supports and service authorization request shall include justification and explanation if a rehabilitation engineer or certified rehabilitation specialist is needed.
[ 7. 6. ] Providers shall develop and maintain individual-specific documentation that supports the provider's claims for payment. Claims that are not supported by individual-specific documentation shall be subject to payment recovery actions by DMAS.
[ 8. 7. ] Additional charges for shipping, freight, or delivery are prohibited because these services are considered all-inclusive in a provider's charge for the product.
[ 9. 8. ] All products must be delivered, demonstrated, installed, and in working order prior to submitting any claim for the products to Medicaid.
[ 10. Providers of the AT service shall not be spouses, parents, or guardians of the individual who is receiving waiver services. 9. ] Providers that supply the AT service for the waiver individual may not perform assessments or consultation or write specifications for that individual. Any request for a change in cost, either an increase or a decrease, requires justification and supporting documentation of [ medical need necessity ] and service authorization by DMAS or its designee. The provider shall receive a copy of the professional evaluation to purchase the items recommended by the professional. If a change is necessary, then the provider shall notify the assessor to ensure the changed items meet the individual's needs.
[ 11. 10. ] All equipment or supplies already covered by a service provided for in the State Plan shall not be purchased under the AT service.
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. [ The plan for supports per requirements detailed in 12VAC30-122-120. ] The service authorization to be completed by the support coordinator may serve as the plan for supports for the provision of AT service. The service authorization request shall be submitted to DMAS or its designee in order for service authorization to occur;
b. [ For AT services, written Written ] documentation regarding the process and results of ensuring that the item is not covered by the State Plan for Medical Assistance as durable medical equipment and supplies;
c. Documentation of the recommendation for the item by an independent professional consultant;
d. Documentation of the date services are rendered and the amount of service that is needed;
e. Any other relevant information regarding the device or modification;
f. Documentation in the support coordination record of notification by the designated individual or individual's representative family/caregiver of satisfactory completion or receipt of the service or item; and
g. Instructions regarding any warranty, repairs, complaints, or servicing that may be needed.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not [ supported substantiated ] by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-280. Benefits planning service. [ (Reserved.) ].
[ A. Service description. Benefits planning is an individualized analysis and consultation service. This service assists recipients of a DD Waiver and social security (SSI, SSDI, SSI/SSDI) to understand their personal benefits and explore their options regarding working, how to begin employment, and the impact employment will have on their state and federal benefits. This service includes education and analysis about current benefits status and implementation and management of state and federal work incentives as appropriate. Benefits planning involves the development of written resource materials that aid individuals and their families/legal representatives in understanding current and future rewards that come from working, thereby reducing uncertainties associated with losing necessary supports and benefits if they choose to work or stay on the job. This service facilitates individuals in making informed choices concerning the initiation of work. Furthermore, it provides information and education to individuals currently employed in making successful transition to financial independence.
B. Criteria and allowable activities. Each of the allowable activities is available contingent on the individual meeting criteria for receipt of the service activity. Receipt of this service shall not be tied to the receipt of any other covered waiver or Medicaid service. This service may be authorized one time per allowable activity per individual per calendar year. However, a service may be reauthorized within a calendar year if the individual's situation has changed in terms of disability conditions, benefit type, or employment status. Allowable activities include the following, which may be appropriate for the individual as documented in his plan for supports:
1. Pre-employment benefits review that may include:
a. Benefits planning query (BPQY) from Social Security Administration (SSA). Description: A BPQY provides information about an individual's disability cash benefits, health insurance, scheduled continuing disability reviews, representative payee, and work history, as stored in SSA's electronic records. The BPQY is an important planning tool for the individual or other person who may be developing customized services for an individual who expresses interest in employment or remaining on the job.
b. Pre-employment benefits summary and analysis (BS&A). Description: Work with and on behalf of the individual to develop a benefits and net income analysis report with both a current scenario and at least two other potential scenarios involving Social Security work incentives.
c. Employment change benefits summary and analysis. Description: Work with and on behalf of the individual when the individual experiences a change in employment status to develop a benefits and net income analysis report with both a current scenario and at least two other potential scenarios involving Social Security work incentives.
2. Work incentives development or revisions (PASS, IRWE, BWE, IDA): Work with the individual and family/legal representative to develop:
a. Plan to achieve self-support (PASS):
(1) Part 1 description: In collaboration with the individual and support system, develop a plan to achieve self-support (PASS) and ensure submission to the SSA.
(2) Part 2 description: Ensure the approval of the PASS plan from the SSA PASS cadre through modifications or other appropriate services.
b. Impairment related work expenses (IRWE). Description: IRWEs reduce the amount of income that Social Security counts against an individual's benefits by deducting the expense from their total countable wages. In order to qualify for the IRWE, the expense shall be related to the individual's disability, work, and be an expense without which the individual cannot work. This service involves working with the individual to develop and submit appropriate forms and supporting documents to SSA to successfully obtain the IRWE work incentive.
c. Blind work expenses (BWE). Description: Work with and on behalf of an individual confirmed to be blind to develop and submit appropriate forms and supporting documents to SSA to successfully obtain the BWE work incentive. Given these circumstances, SSI will not count any earned income when the primary diagnosis is blindness and the expense is reasonably attributed to earning the income, that is, guide dog, transportation to and from work, etc.
d. Individual development accounts (IDA). Description: Work with and on behalf of the individual to develop matched savings accounts to assist the individual in saving toward the purchase of a lifelong asset such as a home.
e. Student earned income exclusion (SEIE). Description: Work with and on behalf of the individual to develop and submit appropriate documents to SSA to receive benefits under the SEIE work incentive. SEIE allows individuals younger than 22 years of age who regularly attend school or are involved in a vocational education program to exclude earned income up to a certain amount per a month.
f. Medicaid while working (Social Security Act § 1619(b)). Description: Work with and on behalf of the individual to develop and submit an appropriate letter and supporting documents to SSA, Virginia Department of Social Services (VDSS), and Medicaid to receive benefits under § 1619(b), which provides the continuation of Medicaid when a beneficiary loses his SSI due to earnings above the SSI threshold.
g. Medicaid works (Virginia's Medicaid Buy-In Program). Description: Work with and on behalf of the individual who is currently eligible for or receiving Medicaid to complete and submit the Medicaid Works agreement and supporting documents to the VDSS to enroll in the Medicaid Buy-In Program (may include Medicaid application or updating the resource section of the Medicaid application). This enables workers with disabilities the opportunity to earn higher income and retain more in savings or resources than is typically allowed by Medicaid.
h. Work incentive revisions. Description: Work with and on behalf of the individual to revise one of the work incentives plans listed in this subdivision B 2 as determined necessary by a significant change in status.
3. Resolution of SSA benefits issues (e.g., overpayments, subsidies, student earned income exclusion, Medicaid while working):
a. Overpayments. Description: Work with and on behalf of the individual to address Social Security overpayments that arise.
b. Subsidies. Description: Work with and on behalf of the individual to develop and submit appropriate documents to SSA to receive the subsidy work incentive.
c. Work activity reports. Description: Assist the individual family/legal representative in filling out and returning forms to SSA.
4. Other services:
a. ABLEnow. Description: Work with and on behalf of the individual and family, if applicable, to open an ABLEnow account.
b. Financial health assessment. Description: The financial health assessment (FHA) is a tool used to gauge an individual's understanding of his current financial situation.
C. Service units and limitations. Providers may not bill for waiver benefits planning services while the eligible individual has an open employment services case with DARS and is eligible for the same service through DARS.
1. The annual year limit for benefits planning services is $3,000. No unspent funds from one plan year may be accumulated and carried over to subsequent plan years.
2. Hourly limits per activity:
a. Plan for Achieving Self-Support-Part 1 7.0 hours.
b. Plan for Achieving Self Support-Part 2 12.5 hours.
c. Impairment Related Work Expense 9.0 hours.
d. Blind Work Expense 9.0 hours.
e. Section 1619(b) Medicaid 4.5 hours.
f. Student Earned Income Exclusion 9.0 hours.
g. Subsidy 9.0 hours.
h. Work Activity Reports: 6.0 hours.
i. Medicaid Works 5.5 hours.
j. Overpayment 3.5 hours.
k. Benefits Planning Query 1.0 hours.
l. Pre-Employment BSA 7.0 hours.
m. WorkWORLD Summary and Analysis 7.0 hours.
n. Individual Development Accounts 7.0 hours.
o. Section 301/Able Now 4.5 hours.
p. Financial Health Assessment 3.5 hours.
q. WI Revisions 7.0 hours.
D. Provider qualifications and requirements.
1. All providers of benefits planning services shall maintain and adhere to current, signed participation agreements with DMAS. The provider designated in this agreement shall directly submit claims to DMAS for reimbursement.
2. Eligible providers for benefits planning services shall possess written verification that they are one of the following:
a. A nationally certified SSA community work incentive coordinator (CWIC); or
b. A DARS certified work incentive specialist advocate (WISA) approved vendor.
3. Only providers that have completed required community financial empowerment and financial literacy training from the Consumer Financial Protection Bureau (CFPB) and Your Money, Your Goals will be eligible to receive payment for a completed financial health assessment.
E. Documentation requirements for service providers.
1. Providers shall include in each individual's record:
a. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
b. Documentation that shall confirm the amount of time spent with the individual, as well as the amount of time dedicated to completion of the work surrounding the benefits planning activity/document.
c. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.
d. All documents shall be completed as they relate to benefits planning activities. If the individual or the family has withdrawn from the process prior to the document's completion, all portions that were completed should be documented along with a note that describes the circumstances during each session.
e. A written review supported by documentation in the individual's record shall be submitted to the support coordinator quarterly, during any quarters in which the service was provided, with the plan for supports if modified.
f. Documentation that all available and appropriate funding sources (including those offered by Virginia Medicaid State Plan, DARS, and the Department of Education), have been explored and exhausted.
g. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims that are not supported by appropriate documentation shall be subject to recovery by DMAS as a result of utilization reviews and audits. ]
12VAC30-122-290. Center-based crisis support service.
A. Service description. Center-based crisis support service means planned crisis prevention and emergency crisis stabilization services in a crisis therapeutic home using planned and emergency admissions. [ This service is designed for individuals who will need ongoing crisis supports. ] Planned admissions shall be provided to individuals receiving crisis services and who need temporary, therapeutic interventions outside of their home setting to maintain stability. Emergency admissions shall be provided to individuals who are experiencing an identified behavioral health need or behavior challenge that is preventing them from reaching stability within their home settings. Center-based crisis support service shall be covered in the FIS, CL, and BI waivers.
B. Criteria and allowable activities.
1. Center-based crisis support service is designed for individuals with a history of at least one of the following:
a. Psychiatric hospitalization;
b. Incarceration;
c. Residential or day placement that was terminated; or
d. Behavior that has significantly jeopardized placement.
2. In addition, the individual shall meet at least one of the following:
a. Is currently experiencing a marked reduction in psychiatric, adaptive, or behavioral functioning;
b. Is currently experiencing an increase in emotional distress;
c. Currently needs continuous intervention to maintain stability; or
d. Is causing harm to himself or others.
3. The individual shall also be:
a. At risk of psychiatric hospitalization;
b. At risk of emergency ICF/IID placement;
c. At immediate risk of loss of community service due to severe situational reaction; or
d. Actually causing harm to himself or others.
4. Allowable activities shall include as appropriate for the individual as documented in the plan for supports:
a. A variety of types of face-to-face assessments (e.g., psychiatric, neuropsychiatric, psychological, behavioral) and stabilization techniques;
b. Medication management and monitoring;
c. Behavior assessment and positive behavior support;
d. Intensive care coordination with other agencies or providers to maintain the individual's community placement;
e. Training for family members/caregivers and providers in positive behavior supports;
f. Skill building related to the behavior creating the crisis such as self-care or ADLs, independent living skills, self-esteem, appropriate self-expression, coping skills, and medication compliance; and
g. Supervising the individual in crisis to ensure his safety and that of other persons in the environment.
C. Service units and limitations. Center-based crisis support service shall be limited to six months per ISP year and shall be authorized in increments of up to a maximum of 30 consecutive days with each authorization. Center-based crisis support service shall not be provided during the occurrence of the following waiver services and shall not be billed concurrently (i.e., same dates and times): (i) group home residential service, (ii) sponsored residential service, (iii) supported living residential service, or (iv) respite service. Center-based crisis support service is available through a waiver only when it is not available through the State Plan.
D. Provider qualifications and requirements.
1. Providers shall meet all of the requirements set out in 12VAC30-122-110 through 12VAC30-122-140.
2. Providers shall have current signed participation agreements with DMAS and shall directly provide the services and bill DMAS for Medicaid reimbursement.
3. Providers shall renew their participation agreements as directed by DMAS.
4. Providers for adults shall be licensed by DBHDS as providers of Group Home Service-REACH (Regional Education Assessment Crisis Services Habilitation) or, for children, a residential group home-REACH for children and adolescents with co-occurring diagnosis of developmental disability and behavioral health needs.
5. Center-based crisis support service shall be provided by a licensed mental health professional (LMHP), LMHP-supervisee, LMHP-resident, LMHP-RP, certified pre-screener, QMHP, QDDP, or [ for skill-building and supervising the individual in crisis, ] a DSP under the supervision of one of the professionals listed in this subdivision D 5.
6. Providers shall ensure that [ DSP ] staff meet provider [ training and ] competency training requirements as specified in 12VAC30-122-180.
7. Providers shall develop and maintain individual-specific contemporaneous documentation that supports the provider's claims for payment. Claims that are not supported by individual-specific documentation shall be subject to payment recovery actions by DMAS.
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
b. Supporting documentation that has been developed (or revised, in the case of a request for an extension) and submitted to the to the support coordinator for authorization within 72 hours of the face-to-face assessment or reassessment.
c. Documentation [ indicating the dates and times of crisis services, the amount and type of service provided, and specific information about the individual's response to the services and supports shall be recorded in the individual's record as detailed in 12VAC30-122-120 ].
d. Documentation maintained for routine supervision and oversight of all services provided by direct support professional staff. All significant contacts shall be documented and dated.
2. [ A supervisor meeting the requirements of 12VAC35-105 shall provide supervision of direct support professional staff. Documentation of supervision shall be (i) completed, (ii) signed by the staff person designated to perform the supervision and oversight, and (iii) include the following: Supervision of DSPs shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight. ]
[ a. Date of contact or observation;
b. Person contacted or observed;
c. Summary about direct support professional staff performance and service delivery; and
d. Any action planned or taken to correct problems identified during supervision and oversight. ]
3. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-300. Community-based crisis support service.
A. Service description. Community-based crisis support service means [ a service planned crisis prevention and emergency crisis stabilization services ] provided to individuals experiencing crisis events that put them at risk for homelessness, incarceration, or hospitalization or that creates danger to self or others. This service shall provide [ ongoing ] supports to individuals in their homes and other community settings. This service provides temporary intensive services and supports that avert emergency psychiatric hospitalization or institutional placement or prevent other out-of-home placement. This service shall be designed to stabilize the individual and strengthen the current living situation so that the individual can be maintained during and beyond the crisis period. Community-based crisis support service shall be covered in the FIS, CL, and BI waivers.
B. Criteria and allowable activities.
1. Community-based crisis support service provides ongoing supports to the individual who may have:
a. A history of multiple psychiatric hospitalizations, frequent medication changes, or setting changes; or
b. A history of requiring enhanced staffing due to the individual's mental health or behavioral issues.
2. To be approved to receive this service, the individual shall have a history of at least one of the following:
a. Previous psychiatric hospitalization;
b. Previous incarceration;
c. Residential or day placement that was terminated; or
d. Behavior that has significantly jeopardized placement.
3. In addition, the individual shall meet at least one of the following:
a. Is experiencing a marked reduction in psychiatric, adaptive, or behavioral functioning;
b. Is experiencing an increase in extreme emotional distress;
c. Needs continuous intervention to maintain stability; or
d. Is actually causing harm to himself or others.
4. The individual shall also be:
a. At risk of psychiatric hospitalization;
b. At risk of emergency ICF/IID placement;
c. At immediate threat of loss of community service due to a severe situational reaction; or
d. Actually causing harm to himself or others.
5. Community-based crisis support service allowable activities shall be provided in either the individual's home or in community settings, or both. Crisis staff shall work directly with the individual and with his current support provider or his family/caregiver, or both. [ This service includes supports during the provision of any other waiver service and may be billed concurrently (i.e., same dates and times). ]
6. This service is provided using, for example, coaching, teaching, modeling, role-playing, problem solving, or direct assistance. Allowable activities shall include, as may be appropriate for the individual as documented in his plan for supports:
a. Psychiatric, neuropsychiatric psychological, and behavioral assessments and stabilization techniques;
b. Medication management and monitoring;
c. Behavior assessment and positive behavior support;
d. Intensive care coordination with agencies or providers to maintain the individual's community placement;
e. Family/caregiver training in positive behavioral supports to maintain the individual in the community;
f. Skill building related to the behavior creating the crisis such as self-care or ADLs, independent living skills, self-esteem, appropriate self-expression, coping skills, and medication compliance; and
g. Supervision to ensure the individual's safety and the safety of others in the environment.
C. Service units and limitations. Community-based crisis support service is provided in an hourly service unit and may be authorized for up to 24 hours per day if necessary in increments of no more than 15 days at a time. The annual limit is 1,080 hours. Requests for additional community-based crisis support service in excess of the 1,080-hour annual limit will be considered if justification of [ medical necessity individual need ] is provided. This service is only available through a waiver when it is not available through the State Plan.
D. Provider qualifications and requirements.
1. Providers shall meet all of the requirements set out in 12VAC30-122-110 through 12VAC30-122-140.
2. Providers of all community-based crisis support service shall have current signed participation agreements with DMAS and shall directly provide the service and bill DMAS for Medicaid reimbursement. These providers shall renew their participation agreements as directed by DMAS.
3. Providers shall be licensed by DBHDS as providers of [ mental health outpatient or ] crisis stabilization service-REACH (Regional Education Assessment Crisis Services Habilitation). Community-based crisis support service shall be provided by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a certified pre-screener, QMHP, or QDDP.
[ 4. Providers shall ensure that staff providing community-based crisis support service meet provider competency training requirements as specified in 12VAC30-122-180. ]
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
b. Supporting documentation that has been developed (or revised, in the case of a request for an extension) and submitted to the support coordinator for authorization within 72 hours of the face-to-face assessment or reassessment.
c. Documentation [ indicating the dates and times of service, the amount and type of service provided, and specific information about the individual's responses to the services and supports as detailed in 12VAC30-122-120 ].
[ d. Documentation confirming the individual's amount of time in the service and providing specific information regarding the individual's response to various settings and supports as agreed to in the plan for supports. Observation of the individual's responses to the service shall be available in at least a daily note. Data shall be collected as described in the plan for supports, analyzed to determine if the strategies are effective, summarized, then clearly documented in the progress notes or support checklist.
e. d. ] Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual. Documentation shall include all correspondence and contacts related to the individual.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting contemporaneous documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-310. Community coaching service.
A. Service description. Community coaching is a service designed for individuals who need one-to-one support in a variety of community settings in order to build a specific skill or set of skills to address particular barriers that prevent individuals from participating in activities of community engagement. In addition to skill building, this service includes routine and safety supports. Community coaching service shall be covered in the FIS, CL, and BI waivers.
B. Criteria and allowable activities. Community coaching service shall be provided to individuals who require one-to-one support to address identified barriers in their plans for supports that prevent them from participating in the community engagement service. Community coaching activities shall be documented in the plan for supports and be sensitive to the individual's age, abilities, and personal preferences. Allowable activities shall include, as may be appropriate for the individual as documented in his plan for supports:
1. One-on-one skill building and coaching to facilitate participation in community activities and opportunities such as:
a. Activities and public events in the community;
b. Community education, activities, and events; and
c. Use of public transportation if available and accessible.
2. Skill building and support in positive behavior, relationship building, and social skills.
3. Routine supports with the individual's self-management, eating, and personal care needs in the community.
4. Assuring the individual's safety through one-to-one supervision in a variety of community settings.
[ 5. Monitoring the individual's health and physical condition and providing supports with medication and other medical needs.
6. Providing routine supports and safety supports with transportation to and from community locations and resources. ]
C. Service units and limitations.
1. The unit of service shall be one hour.
2. The community coaching service, alone or in combination with the community engagement service, group day service, workplace assistance service, or supported employment service shall not exceed 66 hours per week.
3. This service shall be provided at a ratio of one staff to one individual. This service shall not be provided within a group setting. [ The service may be provided in the community in conjunction with other Medicaid services delivered in a group of individuals for the purpose of addressing socialization needs when supported by the plan for supports. Group participation will be permitted on a limited basis. ]
D. Provider qualifications and requirements.
1. Providers shall meet all of the requirements set out in 12VAC30-122-110 through 12VAC30-122-140.
2. Providers shall be licensed by DBHDS as providers of the non-center-based day support service.
3. Providers shall have a current, signed provider participation agreement with DMAS to provide this service. The provider designated in the participation agreement shall directly provide the service and bill DMAS for reimbursement.
4. Providers shall ensure that staff who provide the community coaching service meet provider [ competency ] training [ and competency ] requirements as specified in 12VAC30-122-180.
5. The DSP providing community coaching service shall not be an immediate family member of an individual receiving the community coaching service. For an individual receiving the sponsored residential service, the DSP providing the community coaching service shall not be a member of the sponsored family residing in the sponsored residential home.
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. A copy of the completed, standard, age-appropriate assessment form as detailed in 12VAC30-122-200.
b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
c. Documentation [ confirming attendance and the amount of the individual's time in service and providing specific information regarding the individual's response to various settings and supports. Observations of the individual's responses to service shall be available in at least a daily note. as detailed in 12VAC30-122-120. ] Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, and then clearly documented in the progress notes or supports checklist.
d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.
e. A written review supported by documentation in the individuals' record, which is submitted to the support coordinator at least quarterly with the plan for supports, if modified. [ For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented. ]
f. An attendance log or similar document maintained by the provider that indicates the date, type of service rendered, and the number of hours and units provided, including specific timeframe.
g. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
h. Written documentation of all contacts with the individual's family/caregiver, physicians, providers, and all professionals regarding the individual.
2. [ A supervisor meeting the requirements of 12VAC35-105 shall provide supervision on a semiannual basis of direct support professional staff. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed, signed by the staff person designated to perform the supervision and oversight, and include the following: Supervision of DSPs shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation; (ii) person contacted or observed; (iii) a summary about the direct support professional's performance and service delivery; and (iv) any action planned or taken to correct problems identified during supervision and oversight. ]
[ a. Date of contact or observation;
b. Person contacted or observed;
c. A summary about direct support professional staff performance and service delivery;
d. Any action planned or taken to correct problems identified during supervision and oversight; and
e. On a semiannual basis, the supervisor shall document observations concerning the individual's satisfaction with service provision. ]
3. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-320. Community engagement service.
A. Service description.
1. Community engagement service means a service that supports and fosters an individual's abilities to acquire, retain or improve skills necessary to build positive social behavior, interpersonal competence, greater independence, employability, and personal choices necessary to access typical activities and functions of community life such as those chosen by the general population. The community engagement service may include community education or training and volunteer activities.
2. The community engagement service shall provide a wide variety of opportunities to facilitate and build relationships and natural supports in the community, while utilizing the community as a learning environment. These activities are conducted at naturally occurring times and in a variety of natural settings in which the individual may actively interact with persons without disabilities, other than those who are being paid to support the individual. The activities shall enhance the individual's involvement with the community and facilitate the development of relationships and natural supports.
3. The community engagement service shall be covered in the FIS, CL, and BI waivers.
B. Criteria and allowable activities.
1. The community engagement service shall be provided in the least restrictive and most integrated community settings possible according to the individual's plan for supports and individual choice.
2. Allowable activities shall include, as appropriate for the individual as documented in his plan for supports:
a. Skill building, education, support, and monitoring that assists the individual with the acquisition and retention of skills in the following areas: (i) [ participation in ] activities and public events in the community, (ii) [ participation in ] community educational activities and events, (iii) [ development of ] interests and activities that encourage therapeutic use of leisure time, (iv) [ participation in ] volunteer experiences, [ and ] (v) [ maintaining maintenance of ] contact with family and friends [ , and (vi) development of independence in activities of daily living ].
b. Skill building and education in self-direction designed to enable the individual to achieve one or more of the following outcomes, particularly through community collaborations and social connections developed by the provider (e.g., partnerships with community entities such as senior centers, arts councils): (i) development of self-advocacy skills; (ii) exercise of civil rights; (iii) acquisition of skills that promote the ability to exercise self-control and responsibility over services and supports received or needed; (iv) acquisition of skills that enable the individual to become more independent, integrated, or productive in the community; (v) development of communication skills and abilities; (vi) [ furthering furtherance of ] spiritual practices as desired by the individual; (vii) participation in cultural activities as desired by the individual; (viii) [ developing development of ] skills that enhance career planning goals in the community; (ix) [ developing development of ] living skills; (x) promotion of health and wellness [ , including administration of medication ]; (xi) [ developing development of ] orientation to the community and mobility in the community; (xii) access to and utilization of public transportation [ and so as to develop ] the ability to achieve the desired destination; or (xiii) interaction with volunteers from the community in program activities.
[ c. Providing routine supports and safety supports with transportation to and from community locations and resources. ]
C. Service units and limitations.
1. Community engagement service shall be a tiered service for reimbursement purposes.
2. The unit of service shall be one hour.
3. The community engagement service alone or in combination with the group day service, community coaching service, workplace assistance service, or supported employment service shall not exceed 66 hours per week.
4. [ This Other than time for planning community activities, this ] service shall be delivered in the community and shall not take place in a licensed residential or day setting or in the individual's residence.
5. This service may be provided in groups no larger than three individuals with a minimum of one DSP.
6. This service may include planning community activities with the individuals present in a group of no more than three individuals, although this shall be limited to no more than 10% of the total number of authorized hours per month.
7. Providers shall only be reimbursed for the tier to which the individual has been assigned based on the individual's assessed and documented needs.
D. Provider qualifications and requirements.
1. Providers shall meet all of the requirements set out in 12VAC30-122-110 through 12VAC30-122-140.
[ 1. 2. ] Providers shall be licensed by DBHDS as providers of the non-center-based day support service.
[ 2. 3. ] Providers shall have a current, signed provider participation agreement with DMAS in order to provide this service. The provider designated in the participation agreement shall directly provide the service and bill DMAS for reimbursement.
[ 3. 4. ] Providers shall ensure that [ persons staff ] providing community engagement service meet provider [ competency ] training [ and competency ] requirements as specified in 12VAC30-122-180.
[ 4. 5. ] The DSP providing community engagement service shall not be an immediate family member of an individual receiving the community engagement service. For an individual receiving sponsored residential service, the DSP providing the community engagement service shall not be a member of the sponsored family residing in the sponsored residential home.
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. A copy of the completed, standard, age-appropriate assessment form as described in 12VAC30-122-200.
b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
c. Documentation [ confirming the individual's attendance and the amount of the individual's time in the service and providing specific information regarding the individual's responses to various settings and supports. Observations of the individual's responses to the service shall be available in at least a daily note as detailed in 12VAC30-122-120 ]. Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, and then clearly documented in the progress notes or supports checklist.
d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.
e. [ Documentation that shows that a written summary of a review of supporting documentation was performed with the individual or his family/caregiver, as appropriate, and was A written review supported by documentation in the individual's record, which is ] submitted to the support coordinator at least quarterly with the plan for supports modified [ as appropriate ]. For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented.
f. An attendance log or similar document that is maintained and indicates the date, type of service rendered, and the number of hours and units provided, including the specific timeframe.
g. All correspondence to the individual and individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
h. Written documentation of all contacts with family/caregiver, physicians, providers, and all professionals regarding the individual.
2. [ A supervisor meeting the requirements of 12VAC35-105 shall provide supervision of direct support professional staff. Documentation of supervision shall be completed, signed by the staff person designated to perform the supervision and oversight, and include the following: Supervision of DSP shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight. ]
[ a. Date of contact or observation;
b. Person contacted or observed;
c. A summary about the direct support professional staff performance and service delivery;
d. Any action planned or taken to correct problems identified during supervision and oversight; and
e. Semiannual documentation by the supervisor concerning the individual's satisfaction with service provision. ]
3. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-330. [ (Reserved.) Community guide service. ].
[ A. Service description. Community guide services include direct assistance to promote individuals' self-determination through brokering specific community resources that lead to connection to and independent participation in integrated, independent housing or community activities so as to avoid isolation. This means that community guides investigate and coordinate as necessary the available naturally occurring community resources to facilitate the individual's participation in those resources of interest to the individual. Community guides provide information and directed assistance that aids the individual in developing supportive community relationships and exploring specific community resources that promote implementation of the person-centered plan. This service involves face-to-face contact with the individual to determine the individual's specific interests and exploration of community resources, which may lead to typical community activities or settings in which the individual will engage or reside. In addition, there is a component of supporting the individual that may occur without the individual present. Community guide services involve assisting the individual to identify the type of community options that maximize the individual's opportunities for meaningful engagement and growth in independence. The community guide shall provide the in-depth individualized assistance needed to connect with community activities and foster engagement distinct from the generic activities provided through routine support coordination. This service is designed to be short-term and periodic in nature.
B. Criteria and allowable activities. This service may be provided by persons with one of two emphases:
1. General community guide. This involves the utilization of existing assessment information regarding the individual's general interests to determine specific preferred activities and venues that are available in the individual's community to which the individual desires to be connected (e.g., clubs, special interest groups, physical activities/sports teams, etc.) to promote inclusion and independent participation in the life of the individual's community. The desired result is an increase in daily or weekly natural supports, as opposed to increasing hours of paid supports. Allowable activities include the following for the individual as documented in the individual's plan for supports:
a. Utilize assessment and other information provided by the support coordinator along with an in depth discussion with the individual and people who know the individual. Discussion shall involve an outline of the individual's interests to develop a plan for supports that contains a step by step strategy for the individual and family or friends, as appropriate, to reduce barriers and challenges in accessing community resources or activities to support those interests. The plan for supports shall identify targeted actions that will promote community integration and independent or naturally supported involvement;
b. Assist the individual in connecting to the identified, non-Medicaid funded community resources by researching and contacting the parties responsible for the identified integrated activities, supports, services, or resources delineated in the individual's plan for supports;
c. Provide advocacy and informal counseling that helps guide the individual in problem solving and decision making that enhances the individual's ability to interact and contribute to the local community;
d. Escort the individual or demonstrate on site the means of accessing the identified integrated community activities, supports, services, or resources;
e. Follow up with the individual to determine and document the individual's participation in or utilization of the activities, supports, services, or resources to which the community guide assisted in connecting.
2. Community housing guide. This service involves supporting an individual's move to independent housing by helping with transition and tenancy sustaining activities. The community housing guide shall work in collaboration with the support coordinator, regional housing specialist, and others to support the individual in achieving and sustaining integrated, independent living. Allowable activities include the following as documented in the individual's plan for supports:
a. Conduct a tenant screening that identifies the individual's preferences and barriers related to successful tenancy using the community housing guide tenant screening form;
b. Develop a plan using the community housing guide roadmap form with outcomes and support activities that the community guide shall provide to identify and secure safe, affordable housing to include assisting with implementation and making recommendations to the support coordinator as to waiver support services and activities needed in the individual support plan;
c. Assist with the housing search and application process;
d. Help identify and request resources to cover expenses, such as security deposit, moving costs, furnishings, adaptive aids, environmental modifications, and other one-time expenses;
e. Assist in arranging for and supporting the details of the move;
f. Provide education and training on the role, rights, and responsibilities of the tenant and landlord during the transition from home or congregate setting;
g. Provide training in being a good tenant and lease compliance; support with activities related to household management as part of the transitional support activities;
h. Assist in resolving disputes with landlords or neighbors to reduce risk of eviction or other adverse action during the period of time that community guide services are authorized; and
i. Assist with the housing recertification process if or when requested by the support coordinator or the individual's support team.
C. Service units and limitations.
1. Community guide is expected to be a short, periodically intermittent, intense service associated with a specific outcome. An individual may receive one or more of the two types of community guide services in an ISP year. Each type of community guide service may be authorized for up to six consecutive months, and the cumulative total across both may be no more than 120 hours in a plan year.
2. Community guide activities conducted not in the presence of the individual, such as researching and contacting potential sites, supports, services, and resources, shall not comprise more than 25% of authorized plan for support hours.
3. The community guide shall not supplant, replace, or duplicate activities that are required to be provided by the support coordinator. Prior to accessing funding for this waiver service, all other available and appropriate funding sources, including those offered by Virginia Medicaid State Plan, DARS, and DOE, shall be explored and exhausted.
D. Provider qualifications and requirements.
1. General community guide services shall be provided by persons who have successfully completed and received a certificate of completion for both The Learning Community's:
a. Person-Centered Thinking training; and
b. Community Connections training.
2. The community housing guide services shall be provided by persons who have successfully completed:
a. Person-Centered Thinking training; and
b. DBHDS Independent Housing Curriculum Modules 1-3.
3. Providers shall maintain a signed provider participation agreement with DMAS to provide community guide services.
4. The provider designated in the participation agreement shall directly provide the services and bill DMAS for reimbursement.
E. Documentation requirements for service providers.
1. Providers shall include in each individual's record:
a. A copy of the completed, standard, age-appropriate assessment form as described in 12VAC30-122-200.
b. The provider's plan for supports shall follow requirements detailed in 12VAC30-122-120.
c. Documentation as detailed in 12VAC30-122-120. Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, and clearly documented in the progress notes or supports checklist.
d. Documentation to support units of service delivered and documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.
e. A written review supported by documentation in the individual's record, which is submitted to the support coordinator at least quarterly with the plan for supports, if modified.
f. Documentation that all other available and appropriate funding sources, including those offered by Virginia Medicaid State Plan, DARS, and DOE, have been explored and exhausted.
g. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
h. Written documentation of all contacts with family/caregiver, physicians, formal and informal service providers, and all professionals regarding the individual.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims that are not supported by appropriate documentation shall be subject to recovery by DMAS as a result of utilization reviews and audits. ]
12VAC30-122-340. Companion service.
A. Service description. The companion service provides nonmedical care, socialization, or general support to adults 18 years of age or older. This service shall be provided in either the individual's home or at various locations in the community. The companion service may be coupled [ only ] with [ waiver ] residential support service as defined in the ISP.
1. The companion service shall be provided in accordance with the individual's plan for supports to meet an assessed need of the individual for assistance with IADLs, community access, reminders for medication self-administration, or for support to ensure his safety and shall not be purely recreational in nature.
2. The companion service may be provided and reimbursed either through an agency-directed or a consumer-directed model (12VAC30-122-150).
3. The companion service shall be covered in the FIS and CL waivers.
B. Criteria and allowable activities.
1. Allowable activities shall include, as may be appropriate for the individual and as documented in his plan for supports:
a. Routine supports with IADLs, including meal preparation, community access and activities, and shopping, but companions do not perform these activities as discrete services.
b. Routine supports with light housekeeping tasks, including bed-making, laundry, dusting, and vacuuming, when such services are specified in the individual's plan for supports and are essential to the individual's health and welfare in order to maintain the individual's home environment in an orderly and clean manner.
c. Safety supports in the home and community settings.
2. Individuals choosing the consumer-directed option [ may receive support from a services facilitator and ] shall meet requirements for consumer direction as described in 12VAC30-122-150.
C. Service units and limitations.
1. The unit of service for companion service shall be one hour. The amount that may be included in the plan for supports shall not exceed eight hours per 24-hour day regardless of whether it is an agency-directed or consumer-directed service model, or combination of both.
2. Persons rendering the companion service for reimbursement by DMAS shall not be the individual's spouse [ or other person identified in 12VAC30-122-120 B ].
3. In the consumer-directed service model, any combination of respite service, personal assistance service, and companion service shall be limited to 40 hours per week for a single employer of record (EOR) by the same companion. Companions who live with the individual, either full time or for substantial amounts of time, as set out in 12VAC30-120-935, shall not be restricted to only 40 hours per week for the single EOR. [ The companion shall not provide more than 16 hours of consumer-directed services per day. The 16-hour limit shall include hours worked in one day providing a combination of companion, personal assistance, and respite services. ]
4. A companion shall not be permitted to provide nursing care procedures, including care of ventilators, tube feedings, suctioning of airways, external catheters, or wound care. A companion shall not provide routine support with ADLs.
5. The hours that may be authorized shall be based on documented individual need. No more than two unrelated individuals who are receiving waiver services and who live in the same home shall be permitted to share the authorized work hours of the companion. Providers shall not bill for more than one individual at the same time.
6. Companion service shall not be covered for individuals who are younger than 18 years of age.
7. Companion service shall not be provided by adult foster care providers or any other paid caregivers for an individual residing in that foster care home.
8. For an individual receiving sponsored residential service, companion service shall not be provided by a member of the sponsored family residing in the sponsored residential home.
9. For an individual receiving group home service, sponsored residential service, or supported living service, companion service shall not be provided by an immediate family member.
D. Provider qualifications and requirements.
1. Providers shall meet all of the requirements set out in 12VAC30-122-110 through 12VAC30-122-140.
2. Licensure requirements for agency-directed service. For companion service, the provider shall be licensed by DBHDS as either a residential service provider, supportive in-home residential service provider, day support service provider, or respite service provider or shall meet the DMAS criteria to be a personal care service or respite care service provider [ as defined in 12VAC30-122-460 ].
3. Persons functioning as companions shall meet the following requirements:
a. Be at least 18 years of age;
b. Be able to read and write English to the degree required to function in this capacity and create and maintain the required documentation to support billing and possess basic math skills;
c. Be capable of following a plan for supports with minimal supervision and physically able to perform the required work;
d. Possess a valid Social Security Number that has been issued by the Social Security Administration to the person who is to function as the companion;
e. Be capable of aiding in IADLs; [ and ]
f. Receive a tuberculosis screening according to the requirements of the Virginia Department of Health [ ; and
g. For consumer directed companions, be willing to attend training at the individual's or family/caregiver's request ].
4. Supervision requirements for agency-directed companion service.
a. A supervisor shall provide ongoing supervision of all companions.
b. For DBHDS-licensed entities, the provider shall employ or subcontract with [ and directly supervise at least a Qualified Developmental Disabilities Professional (QDDP) who shall provide ongoing supervision of all companions a supervisor meeting the requirements of 12VAC35-105 to provide supervision on a semiannual basis of direct support professional staff ].
c. For companion service providers [ , that meet the DMAS criteria to be a personal care service or respite care service provider, ] the provider shall employ or subcontract with and directly supervise an RN or an LPN who shall provide ongoing supervision of all companions. The supervising RN or LPN shall have at least one year of related clinical nursing experience that may include work in an acute care hospital, public health clinic, home health agency, ICF/IID, or nursing facility or shall have a bachelor's degree in a human services field and at least one year of experience working with individuals with developmental disabilities.
d. The supervisor shall make a home visit to conduct an initial assessment prior to the start of service for all individuals enrolled in the waiver requesting and who have been approved to receive companion service. The supervisor shall also perform any subsequent reassessments or changes to the plan for supports. All changes that are indicated for an individual's plan for supports shall be reviewed with and agreed to by the individual and, if appropriate, the family/caregiver.
e. The supervisor shall make supervisory home visits as often as needed to ensure both quality and appropriateness of the service. The minimum frequency of these visits shall be every 30 to 90 days under the agency-directed model, depending on the individual's needs.
f. Based on continuing evaluations of the companion's performance and individual's needs, the supervisor shall identify any gaps in the companion's ability to function competently and shall provide training as indicated.
[ g. All individuals shall have a backup plan prior to initiating services in cases of emergency or should the provider be unable to render services as needed. This backup plan shall be shared with the provider and support coordinator at the onset of services and updated with the provider and support coordinator as necessary. ]
5. Providers shall ensure that [ all ] staff providing agency-directed companion service meet provider [ competency ] training [ and competency ] requirements as specified in 12VAC30-122-180.
6. Service facilitation requirements for companion service shall be the same as those set forth in 12VAC30-122-150.
7. Family members as providers in agency-directed companion service shall meet the same limits and requirements set out in 12VAC30-122-120 B.
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. A copy of the completed, standard, age-appropriate assessment form as described in 12VAC30-122-200.
b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
c. Documentation [ confirming the individual's amount of time in service and providing specific information regarding the individual's response to various settings and supports. Documentation shall be available in at least a daily note as detailed in 12VAC30-122-120 ]. [ Data Documentation ] shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, then clearly documented in the progress notes or support checklist.
d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.
e. A written review supported by documentation in the individual's record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified. [ For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented. ]
f. All correspondence to the individual and individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
g. Written documentation of all contacts with the individual's family/caregiver, physicians, providers, and all professionals regarding the individual.
h. Documentation that is maintained for routine supervision and oversight of all service provided by the companion. All significant contacts shall be documented and dated.
i. Documentation of supervision that is completed, signed by the staff person designated to perform the supervision and oversight, and includes the following:
(1) Date of contact or observation;
(2) Person contacted or observed;
(3) A summary about the companion's performance and service delivery;
(4) Any action planned or taken to correct problems identified during supervision and oversight; and
[ (5) On a semiannual basis, documentation of observations concerning the individual's satisfaction with service provision. ]
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-350. Crisis support service.
A. Service description. Crisis support service is designed for individuals experiencing circumstances such as (i) marked reduction in psychiatric, adaptive, or behavioral functioning; (ii) an increase in emotional distress; (iii) needing continuous intervention to maintain stability; or (iv) causing harm to themselves or others. Crisis support service means intensive supports by trained and, where applicable, licensed staff in crisis prevention, crisis intervention, and crisis stabilization for an individual who is experiencing an episodic behavioral or psychiatric event in the community that has the potential to jeopardize the current community living situation. This service is designed to prevent the individual from experiencing an episodic crisis that has the potential to jeopardize his current community living situation, to intervene in such a crisis, or to stabilize the individual after the crisis. This service shall prevent escalation of a crisis, maintain safety, stabilize the individual, and strengthen the current living situation so that the individual can be supported in the community beyond the crisis period. Crisis support service shall be covered in the FIS, CL, and BI waivers.
B. Criteria and allowable activities. Crisis support service may include as appropriate and necessary:
1. Crisis prevention services, which provide [ ongoing ] assessment of an individual's medical, cognitive, and behavioral status as well as predictors of self-injurious, disruptive, or destructive behaviors, with initiation of positive behavior supports to resolve and prevent future occurrence of crisis situations. Crisis prevention services shall also include training for family/caregivers to avert further crises and to maintain the individual's typical routine to the maximum extent possible. Crisis prevention services shall also encompass supporting the family and individual through team meetings, revising the behavior plan or guidelines, and other activities as changes to the behavior support plan are implemented and residual concerns from the crisis situation are addressed.
2. Crisis intervention services, which shall be used during a crisis to prevent further escalation of the situation and to maintain the immediate personal safety of those involved. Crisis intervention services shall be a short-term service providing highly structured intervention that can include, for example, temporary changes to the person's residence, changes to the person's daily routine, and emergency referral to other care providers. Crisis intervention staff shall model verbal deescalation techniques including active listening, reflective listening, validation, and suggestions for immediate changes to the situation.
3. Crisis stabilization, which entails gaining a full understanding of the factors that contributed to the crisis once the immediate threat has resolved and there is no longer an immediate threat to the health and safety of the individual or others. Crisis stabilization services shall be geared toward gaining a full understanding of all of the factors that precipitated the crisis and may have maintained it until trained staff from outside the immediate situation arrived. These services result in the development of new plans that may include environmental modifications, interventions to enhance communication skills, or changes to the individual's daily routine or structure. Crisis stabilization staff shall train family/caregivers and other persons significant to the individual in techniques and interventions to avert future crises.
C. Service units and limitations.
1. Crisis support service shall be authorized or reauthorized following a documented face-to-face assessment conducted by a QDDP [ or QMHP ].
a. Crisis prevention. The unit of the service shall be one hour and billing may occur up to 24 hours per day if necessary. [ Medically necessary crisis Crisis ] prevention may be authorized for up to 60 days per ISP year. Crisis prevention services include supports during the provision of any other waiver service and may be billed concurrently (i.e., same dates and times).
b. Crisis intervention. The unit of the service shall be one hour and billing may occur up to 24 hours per day if necessary. [ Medically necessary crisis Crisis ] intervention may be authorized in increments of no more than 15 days at a time for up to 90 days per ISP year. Crisis intervention services include supports during the provision of any other waiver service and may be billed concurrently (i.e., same dates and times).
c. Crisis stabilization. The unit of the service shall be one hour and billing may occur up to 24 hours per day if necessary. [ Medically necessary crisis Crisis ] stabilization may be authorized in increments of no more than 15 days at a time for up to 60 days per ISP year. Crisis stabilization services include supports during the provision of any other waiver service and may be billed concurrently (i.e., same dates and times).
2. The crisis support service shall only be available through a waiver when they are not available through the State Plan.
D. Provider qualifications and requirements.
1. Providers shall meet the requirements of 12VAC30-122-110 through 12VAC30-122-140.
2. Providers of crisis support service shall have current signed participation agreements with DMAS and shall directly provide the service and bill DMAS for Medicaid reimbursement. These providers shall renew their participation agreements as directed by DMAS.
3. Crisis support service shall be provided by entities licensed by DBHDS as providers of [ outpatient crisis stabilization service, ] residential crisis stabilization service, or nonresidential crisis stabilization service. Providers shall employ or utilize QDDPs, licensed mental health professionals, or other qualified personnel [ licensed credentialed ] to provide clinical or behavioral interventions. [ For the purposes of services delivery and billing, those individuals who do not have a license or degree are considered nonprofessionals. Those individuals who meet QDDP requirements or are licensed are considered professionals. ]
4. Providers shall ensure that [ DSP ] staff who are providing [ community-based ] crisis support service meet provider [ competency ] training [ and competency ] requirements as specified in 12VAC30-1220-180.
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
b. Supporting documentation that is developed (or revised, in the case of a request for an extension) and submitted to the support coordinator for authorization within 72 hours of the face-to-face assessment or reassessment.
c. Documentation indicating the dates and times of service, the amount and type of service provided, and specific information about the individual's responses to service in the supporting documentation.
d. Documentation of provider qualifications that is maintained for review by DMAS or DBHDS staff and provided upon request from either agency.
e. Documentation [ confirming attendance and the individual's amount of time in service and providing specific information regarding the individual's response to various settings and supports as agreed to in the plan for supports. Observation results shall be available in at least a daily note. as detailed in 12VAC30-122-120. ] Data shall be collected as described in the plan for supports, analyzed to determine if the strategies are effective, summarized, then clearly documented in the progress notes or support checklist.
f. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual. Documentation shall include all correspondence and contacts related to the individual.
g. Documentation that is maintained for routine supervision and oversight of all service provided by direct support professional staff. All significant contacts shall be documented and dated.
2. [ A supervisor meeting the requirements of 12VAC35-105 shall supervise direct support professional staff. Documentation of supervision shall be completed, signed by the staff person designated to perform the supervision and oversight, and include the following: Supervision of DSPs shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight. ]
[ a. Date of contact or observation;
b. Person contacted or observed;
c. A summary about direct support professional staff performance and service delivery;
d. Any action planned or taken to correct problems identified during supervision and oversight; and
e. On a semiannual basis, the supervisor shall document observations concerning the individual's satisfaction with service provision. ]
3. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-360. Electronic home-based support service.
A. Service description. Electronic home-based support service shall provide devices, equipment, or supplies, based on current technology to enable the individual to more safely live and participate in his community while decreasing the need for other services such as staff supports. The equipment or devices shall be purchased for the individual and typically shall be installed in the individual's home. Portable hand-held devices may be used by the individual at home or in the community. These devices and this service shall support the individual's greater independence and self-reliance in the community. This service may also include ongoing electronic monitoring, which is the provision of oversight and monitoring within the home through off-site monitoring. The electronic home-based service shall be covered in the FIS, CL, and BI waivers.
B. Criteria and allowable activities.
1. In order to qualify for the electronic home-based support (EHBS) service, the individual shall be at least 18 years of age and [ physically ] capable of using the equipment provided via EHBS service.
2. A preliminary needs assessment shall be completed by [ a technology specialist an independent professional consultant ] to determine the best type and use of technology and overall cost effectiveness of various options. This assessment shall be submitted to the DMAS designee for service authorization prior to the delivery of any goods and services and prior to the submission of any claims for Medicaid reimbursement. The [ technology specialist independent professional consultant ] conducting the preliminary assessment may be an occupational therapist, or other similarly credentialed specialist, who is licensed or certified by the Commonwealth and specializes in assistive technologies, mobile technologies, and current accommodations for individuals with developmental disabilities.
3. EHBS service shall support training in the use of these goods and services, ongoing maintenance, and monitoring to address an identified need in the individual's ISP, including improving and maintaining the individual's opportunities for full participation in the community.
4. Items or services purchased through EHBS service shall be designed to decrease the need for other Medicaid services, such as reliance on staff supports, promote inclusion in the community, and increase the individual's safety in the home environment.
C. Service units and limits.
1. The ISP year limit for this service shall be $5,000. No unspent funds from one plan year shall be accumulated and carried over to subsequent plan years.
2. Receipt of EHBS service shall not be tied to the receipt of any other covered waiver or Medicaid service. Equipment or supplies already covered by any other Medicaid covered service shall be excluded from coverage by this waiver service.
3. EHBS service shall be provided in the least expensive manner possible that will meet the identified need of the individual enrolled in the waiver and shall be completed within the [ calendar ISP ] year.
4. EHBS service shall not be covered for individuals who are receiving residential supports that are reimbursed on a daily basis, such as group home, or sponsored or supported living residential service.
D. Provider requirements.
1. Providers shall meet all of the requirements of 12VAC30-122-110 through 12VAC30-122-140.
2. An EHBS service provider shall be one of the following:
a. A Medicaid-enrolled licensed personal care agency;
b. A Medicaid-enrolled durable medical equipment provider;
c. A CSB or BHA;
d. A center for independent living;
e. A licensed and Medicaid-enrolled home health provider;
f. An EHBS manufacturer [ or a company ] that has the ability to provide electronic home-based equipment, direct services (i.e., installation, equipment maintenance, and service calls), and monitoring; or
g. A PERS manufacturer [ or a company ] that is Medicaid-enrolled and has the ability to provide electronic home-based equipment, direct services (i.e., installation, equipment maintenance, and service calls), and monitoring services.
3. Providers of this service shall have a current, signed participation agreement with DMAS. Providers as designated on this agreement shall render this service directly and shall bill DMAS for Medicaid reimbursement.
4. The provider of ongoing monitoring systems shall provide an emergency response center with fully trained operators who are capable of (i) receiving signals for help from an individual's equipment 24 hours a day, 365 or 366 days per year as appropriate; (ii) determining whether an emergency exists; and (iii) notifying the appropriate responding organization or an emergency responder that the individual needs help.
5. The EHBS service provider shall have the primary responsibility to furnish, install, maintain, test, and service the equipment, as required, to keep it fully operational. The provider shall replace or repair the device within 24 hours of the individual's notification of a malfunction of the unit or device.
6. The EHBS service provider shall properly install all equipment and shall furnish all supplies necessary to ensure that the system is installed and working properly.
7. The EHBS service provider shall install, test, and demonstrate to the individual and family/caregiver, as appropriate, the unit or device before submitting a claim to DMAS. The provider responsible for installation of devices shall document the date of installation and training in use of the devices.
8. The provider of off-site monitoring shall document each instance of action being taken on behalf of the individual. This documentation shall be maintained in this provider's record for the individual and shall be provided to either DMAS or DBHDS upon demand. The record shall document all of the following:
a. Delivery date and installation date of the EHBS;
b. The signature of the individual or his family/caregiver, as appropriate, verifying receipt of the EHBS device;
c. Verification by a test that the EHBS device is operational, monthly or more frequently as needed;
d. Updated and current individual responder and contact information, as provided by the individual or the individual's care provider or support coordinator/case manager; and
e. A case log documenting the individual's utilization of the system and contacts and communications with the individual or his family/caregiver, as appropriate, support coordinator, or responder.
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. [ The provider's plan for supports per requirements detailed in 12VAC30-122-120. ] The appropriate service authorization to be completed by the support coordinator may serve as the plan for supports for the provision of EHBS service. A rehabilitation engineer may be involved for EHBS service if disability expertise is required that a general contractor may not have. The service authorization request documentation shall include justification and explanation if a rehabilitation engineer is needed. The service authorization request shall be submitted to the state-designated agency or its designee in order for service authorization to occur;
b. Written documentation regarding the process and results of ensuring that the item is not covered by the State Plan for Medical Assistance as durable medical equipment (DME) and supplies, and that the item is not available from a DME provider;
c. Documentation of the recommendation for the item by an independent professional consultant;
d. Documentation of the date service is rendered and the amount of service that is needed;
e. Any other relevant information regarding the device or modification;
f. Documentation in the support coordination record of notification by the designated individual or individual's representative family/caregiver of satisfactory completion or receipt of the service or item; and
g. Instructions regarding any warranty, repairs, complaints, or servicing that may be needed.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-370. Environmental modifications service.
A. Service description. Environmental modifications service [ shall be defined as set out in 12VAC30-122-20 and includes equipment or modifications of a remedial or medical benefit offered in an individual's primary home or the primary vehicle used by the individual to specifically improve the individual's personal functioning. means physical adaptations to the individual's home or primary vehicle that are necessary to ensure the individual's health and welfare or to enable functioning with greater independence. ] Environmental modifications service shall be covered in the FIS, CL, and BI waivers.
B. Criteria and allowable activities.
1. To qualify for environmental modifications (EM) service, the individual enrolled in the waiver shall have a demonstrated need for:
a. Installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies that are necessary for the individual and are consistent with the plan for supports requirements.
b. Modifications to a primary automotive vehicle in which the individual is transported that is owned by the individual, a family member with whom the individual lives or has consistent and ongoing contact, or a nonrelative who provides primary long-term support to the individual and is not a paid provider of environmental modifications.
2. EM service shall encompass those items not otherwise covered in the State Plan for Medical Assistance or through another program.
C. Service units and limits.
1. Environmental modifications (EM) service shall be provided in the least expensive manner possible that will accomplish the modification required by the individual enrolled in the waiver and shall be completed within the calendar year.
2. The maximum funded expenditure per individual for all EM service covered procedure codes (i.e., combined total of EM service items and labor related to these items) shall be $5,000 per calendar year for individuals regardless of the waiver for which EM service is approved and regardless of whether or not the individual changes waivers over the course of the calendar year. The service unit shall always be one for the total cost of all EM being requested for a specific timeframe.
3. EM service shall only be available to individuals enrolled in the waiver who are receiving at least one other waiver service. EM service shall be service authorized by the state-designated agency or its designee for each calendar year with no carry-over of authorized unspent funds across calendar years.
4. Providers of EM service shall not be the spouse, parents, or legal guardians of the individual enrolled in the waiver.
5. Modifications shall not be used to bring a substandard dwelling up to minimum habitation standards.
6. Excluded from coverage under the EM service shall be those adaptations or improvements to the home that are of general utility and that are not of direct medical or remedial benefit to the individual enrolled in the waiver, including carpeting, roof repairs, and central air conditioning. Also excluded shall be modifications that are reasonable accommodation requirements of the Americans with Disabilities Act, (42 USC § 12101 et seq.), the Virginians with Disabilities Act (Title 51.5 (§ 51.5-1 et seq.) of the Code of Virginia), and the Rehabilitation Act (29 USC § 701 et seq.). Adaptations that add to the total square footage of the home shall be excluded from this service. Except when EM service is furnished in the individual's own home, it shall not be provided to individuals who receive residential support service.
7. Modifications shall not be service authorized or covered to adapt living arrangements that are owned or leased by providers of waiver services or those living arrangements that are sponsored by a DBHDS-licensed provider. Specifically, provider-owned or leased settings where residential support service is furnished shall already be compliant with the Americans with Disabilities Act.
8. Environmental modifications to a primary vehicle shall exclude:
a. Adaptations or improvements to the vehicle that are of general utility and are not of direct medical or remedial benefit to the individual;
b. Purchase or lease of a vehicle; and
c. Regularly scheduled upkeep and maintenance of a vehicle, except upkeep and maintenance of the modifications that were covered under the environmental modifications service.
9. EM service shall be provided in accordance with all applicable federal, state, or local building codes and laws.
D. Provider requirements.
1. Providers shall meet all of the requirements set forth in 12VAC30-122-110 through 12VAC30-122-140.
2. An EM service provider shall be one of the following:
a. A Medicaid-enrolled durable medical equipment provider; or
b. A CSB or [ BHS BHA ].
3. Providers of environmental modifications service shall have a current, signed participation agreement with DMAS. Providers as designated on this agreement shall render environmental modifications directly and shall bill DMAS for Medicaid reimbursement.
4. If a provider has previously made environmental modifications, such previous work shall have been completed satisfactorily in order to be authorized for future jobs. A provider shall perform all servicing and repairs that the modification may require for the individual's successful use.
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. [ The provider's plan for supports per requirements detailed in 12VAC30-122-120. ] The appropriate service authorization to be completed by the support coordinator may serve as the plan for supports for the provision of EM service. A rehabilitation engineer may be involved for EM service if disability expertise is required that a general contractor may not have. The service authorization shall include justification and explanation if a rehabilitation engineer is needed. The service authorization request shall be submitted to the state-designated agency or its designee in order for service authorization to occur;
b. Written documentation regarding the process and results of ensuring that the item is not covered by the State Plan for Medical Assistance, for example as durable medical equipment (DME) and supplies and that it is not otherwise available from a DME provider;
c. Documentation of the recommendation for the item by an independent professional consultant if an independent professional consultant is required for the individual's needs;
d. Documentation of the date EM service is rendered and the amount of service that is needed;
e. Any other relevant information regarding the device or modification;
f. Documentation in the support coordinator's record of notification by the designated individual or individual's representative family/caregiver of satisfactory completion or receipt of the service or item; and
g. Instructions regarding any warranty, repairs, complaints, or servicing that may be needed.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-380. Group day service.
A. Service description. Group day service means a service provided to help the individual acquire, retain, or improve skills of self-help, socialization, community integration, career planning, and adaptation via opportunities for peer interactions, community integration, and enhancement of social networks. This service typically shall be offered in a nonresidential setting. Skill-building shall be a component of this service unless the individual has a documented progressive condition, in which case group day service may focus on maintaining skills and functioning and preventing or slowing regression rather than acquiring new skills or improving existing skills. Group day service shall be covered in the FIS, CL, and BI waivers.
B. Criteria and allowable activities. For group day service, an individual shall demonstrate the need for skill-building or supports offered primarily in settings other than the individual's own residence that allows the individual an opportunity for being a productive and contributing member of his community. In addition, group day service shall be available for individuals who can benefit from the supported employment service, but who need group day service as an appropriate alternative or in addition to the supported employment service.
1. Allowable activities shall include, as may be appropriate for the individual as documented in his plan for supports:
a. Developing problem-solving abilities; sensory, gross, and fine motor control abilities; and communication and personal care skills;
b. Developing self, social, and environmental awareness skills;
c. Developing skills as needed in (i) positive behavior, (ii) using community resources, (iii) community safety and positive peer interactions, (iv) volunteering and participating in educational programs in integrated settings, and (v) forming community connections or relationships;
d. Supporting older adults in participating in meaningful retirement activities in their communities (i.e., clubs and hobbies);
e. [ Skill-building and providing routine supports related to ADLs and IADLs.
f. Monitoring the individual's health and physical condition and providing supports with medication and other medical needs.
g. ] Providing safety supports in a variety of community settings; [ and
f. h. ] Career planning and resume developing based on career goals, personal interests, and community experiences [ ; and
i. Providing routine supports and safety supports with transportation to and from community locations and resources ].
2. Group day service shall be coordinated with the therapeutic consultation plan, as applicable.
C. Service units and limits.
1. This service unit shall be one hour. Group day service, alone or in combination with the community engagement service, community coaching service, workplace assistance service, or supported employment service, shall not exceed 66 hours per week. Group day service shall occur one or more hours per day on a regularly scheduled basis for one or more days per week in settings that are separate from the individual's home.
2. Group day service shall be a tiered service for reimbursement purposes. Providers shall only be reimbursed for the individual's assigned level and tier.
3. Group day service staffing ratios shall be based on the activity and the individual's needs as set out in the individual's plan for supports and shall be at least one staff to seven individuals.
4. Providers shall be reimbursed only for the amount of group day service that are rendered as established in the individual's approved plan for supports based on the setting, intensity, and duration of the service to be delivered.
5. In instances where group day service staff are required to ride with the individual to and from group day service, the group day service staff time may be billed as group day service, provided that the billing for this time does not exceed 25% of the total time the individual spent in the group day service activity for that day. Documentation shall be maintained to verify that billing for group day service staff coverage during transportation does not exceed 25% of the total time spent in the group day service for that day.
D. Provider requirements.
1. Providers shall meet all of the requirements of 12VAC30-122-110 through 12VAC30-122-140.
2. Providers of the group day service shall hold either day support or community-based day support current licenses issued by DBHDS.
3. Providers of the group day service shall also be currently enrolled as providers with DMAS. Providers designated on the DMAS provider agreement shall:
a. Render this service directly;
b. Ensure that appropriate documentation of the delivery of service supports claims that are filed for reimbursement; and
c. Comply with HCBS setting requirements per 42 CFR 441.301.
4. Claims that are not supported by appropriate documentation may be subject to recovery by DMAS or its designee due to utilization reviews or audits.
5. [ Supervision of direct support staff shall be provided by a supervisor meeting the requirements of 12VAC35-105. Documentation of supervision shall be completed, signed, and dated by the supervisor and shall include, at a minimum, the following: Supervision of DSPs shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight. ]
[ a. Date of contact or observation;
b. Person contacted or observed;
c. A summary about the direct support professional's performance and service delivery;
d. Any action planned or taken to correct problems identified during supervision and oversight; and
e. On a semiannual basis, the supervisor shall document observations concerning the individual's satisfaction with service provision. ]
6. Providers shall ensure that [ individuals staff ] providing group day service meet provider [ competency ] training [ and competency ] requirements as specified in 12VAC30-122-180.
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. A copy of the most current, completed, standard, age-appropriate assessment form.
b. The provider's plan for supports [ containing, at a minimum, the items detailed in 12VAC30-122-120 A 10 f. per requirements detailed in 12VAC30-122-120. ]
c. Documentation [ that confirms the individual's attendance and the amount of the individual's time in service and provides specific information regarding the individual's responses to various settings and supports. Observations of the individual's responses to the service shall be available in a daily note. Such documentation shall be provided to DMAS or DBHDS upon request. as detailed in 12VAC30-122-120. ] Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, then clearly documented in the progress notes or supports checklist.
d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.
e. A written review supported by documentation in the individuals' record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified. [ For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented. ]
f. An attendance log or similar document that is maintained and that indicates the date, type of service rendered, and the number of hours and units provided, including specific timeframe.
g. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator/case manager, DMAS, and DBHDS.
h. Written documentation of all contacts with the individual's family/caregiver, physicians, providers, and all professionals regarding the individual.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims submitted for reimbursement that are not supported by provider documentation made available to DMAS or its designee shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-390. Group home residential service.
A. Service description. Group home residential service shall consist of skill-building, routine supports, general supports, and safety supports that are provided to enable an individual to acquire, retain, or improve skills necessary to successfully live in the community. This service shall be provided to individuals who are living in (i) a group home or (ii) the home of an adult foster care provider. Group home residential service shall be a tiered service for reimbursement purposes (as described in 12VAC30-122-210) based on the individual's assigned level and tier and licensed bed capacity of the home. [ The number of licensed beds in a setting reimbursed for group home residential services shall not exceed six. Group home settings larger than six licensed beds that became DD Waiver providers prior to March 31, 2021, may continue to operate and receive Medicaid reimbursement. If a group home larger than six licensed beds changes ownership, the group home will be considered a new setting and the licensed bed capacity limit of six beds shall apply for Medicaid reimbursement purposes. ] Group home residential service shall be provided to the individual continuously up to 24 hours per day performed by paid staff that shall be physically present. This service may be provided either individually or simultaneously to more than one individual living in that home, depending on the required support. Group home residential service shall be covered in the CL waiver.
B. Criteria and allowable activities.
1. The allowable activities shall include, as may be appropriate for the individual as documented in his plan for supports:
a. Skill-building and providing routine supports related to ADLs and IADLs;
b. Skill-building and providing routine supports and safety supports related to the use of community resources, such as transportation, shopping, restaurant dining, and participating in social and recreational activities;
c. Supporting the individual in replacing challenging behaviors with positive, accepted behavior for home and community environments;
d. Monitoring the individual's health and physical condition and providing supports with medication and other medical needs;
e. Providing routine supports and safety supports with transportation to and from community locations and resources;
f. Providing general supports, as needed; and
g. Providing safety supports to ensure the individual's health and safety.
2. Group home residential service shall include a skill-building component along with the provision of supports as may be needed by the individuals who are participating.
C. Service units and limits.
1. The unit of service shall be a day. Providers may bill the unit of service if any portion of the plan for supports is provided during that day.
2. Group home residential service shall be authorized for Medicaid reimbursement only when the individual in the CL waiver requires this service and the service is set out in the plan for supports.
3. Group home residential service settings shall comply with the HCBS setting requirements per 42 CFR 441.301. [ In these settings, lease or residency agreements shall comply with and support individual choice of service and setting. ]
D. Provider qualifications and requirements.
1. Providers shall meet all of the requirements set forth in 12VAC30-122-110 through 12VAC30-122-140.
2. The provider of group home residential service for adults who are 18 years of age or older shall be licensed by DBHDS as a provider of the group home residential service or a provider approved by the local department of social services as an adult foster care provider (12VAC35-105-20). Providers of the group home residential service for children (up to the child's 18th birthday) shall be licensed by DBHDS as children's residential providers.
3. All providers of group home residential service shall have a current provider participation agreement with DMAS. Providers designated on this agreement shall render the group home residential service and shall bill DMAS directly for reimbursement.
4. Providers shall ensure that staff providing the group home residential service meet provider [ competency ] training [ and competency ] requirements specified in 12VAC30-122-180.
5. [ A supervisor meeting the requirements of 12VAC35-105-590 shall provide supervision of direct support professional staff. Documentation of supervision shall be completed, signed, and dated by the supervisor who performs the supervision and oversight and shall include the following: Supervision of DSPs shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight. ]
[ a. Date of contact or observation;
b. Person contacted or observed;
c. A summary about the direct support professional's performance and service delivery;
d. Any action planned or taken to correct problems identified during supervision and oversight, and
e. Individual's satisfaction with the provision of this service documented semiannually by the supervisor. ]
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. A copy of the completed, standard, age-appropriate assessment form as specified in 12VAC30-122-200.
b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
c. Documentation [ confirming the individual's days in service and providing specific information regarding the individual's responses to various settings and supports. Observations of the individual's responses to the service shall be available in at least a daily note. as detailed in 12VAC30-122-120. ] Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, then clearly documented in the progress notes or supports checklist.
d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual. Providers' claims that are not adequately supported by corresponding documentation may be subject to recovery of expenditures made.
e. A written review supported by documentation in the individuals' record will be submitted to the support coordinator at least quarterly with the plan for supports, if modified. [ For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented. ]
f. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
g. Written documentation of contacts made with the individual's family/caregiver, physicians, providers, and all professionals concerning the individual.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-400. Group and individual supported employment service.
A. Service description. Group and individual supported employment service may be performed for a single individual (as in individual supported employment (ISE)) or in small groups (as in group supported employment) of individuals (two to eight individuals). This service shall consist of ongoing supports provided by a job coach that enable individuals to be employed in an integrated work setting and may include assisting the individual, either as a sole individual or in small groups, to locate a job or develop a job on behalf of the individual, as well as activities needed by the individual to sustain paid work. Group and individual supported employment service shall be covered in the FIS, CL, and BI waivers.
1. Group and individual supported employment service shall be provided in work settings where persons without disabilities are employed. Group and individual supported employment service shall be designed especially for individuals with developmental disabilities who face impediments to employment due to the nature and complexity of their disabilities, irrespective of age or vocational potential, that is, the individual's ability to perform work.
2. Group and individual supported employment service shall be available to individuals for whom competitive [ integrated ] employment at or above the minimum wage is unlikely without ongoing supports and who because of their disabilities need ongoing support to perform in a work setting. The individual's assessment and ISP shall clearly reflect the individual's need for employment-related skill-building.
3. Group and individual supported employment service shall be provided in one of two models: individual or group.
a. Individual supported employment service shall be one-on-one ongoing support that enables individuals to work in an integrated setting. The outcome of this service shall be sustained paid employment at or above minimum wage in an integrated setting in the general workforce in a job that meets personal and career goals. For this service, reimbursement of supported employment shall be limited to actual documented interventions or collateral contacts by the provider as required by the individual receiving waiver services [ , but reimbursement. Reimbursement ] shall not be [ limited provided ] for the supervisory activities rendered as a normal part of the regular business setting and not for the amount of time the individual enrolled in the waiver is in the supported employment situation.
b. Group supported employment service shall be continuous support provided by staff in a naturally occurring place of employment to groups of two to eight individuals with disabilities and involves interactions with the public and coworkers who do not have disabilities. This service shall be provided in a community setting that promotes integration into the workplace and interaction in the workplace between participants and people without disabilities. Examples include mobile crews and other business-based workgroups employing small groups of workers with disabilities in the community. Group supported employment settings shall comply with the HCBS setting requirements per 42 CFR 441.301.
B. Criteria and allowable activities.
1. Only activities that specifically pertain to the individual shall be allowable activities under the supported employment service, and DMAS shall cover this service only after determining that this service is not available from DARS or the local school system, for individuals younger than 22 years of age [ , for the individual enrolled in the waiver and eligible for school services under IDEA ].
2. To qualify for this service, the individual shall have demonstrated that competitive employment at or above the minimum wage is unlikely without ongoing supports and that because of the individual's disability, he needs ongoing support to perform in a work setting.
3. The plan for supports shall document the amount of supported employment required by the individual.
4. Allowable activities for both individual and group supported employment service include the following job development tasks, supports, and training. For DMAS reimbursement to occur, the individual shall be present, unless otherwise noted, when these activities occur:
a. Vocational or job-related discovery or assessment;
b. Person-centered employment planning that results in employment related outcomes;
c. Individualized job development, with or without the individual present, that produces an appropriate job match for the individual and the employer to include job analysis or determining job tasks, or both. This element shall be limited to individual supported employment service only and shall not be permitted for group supported employment service.
d. Negotiation with prospective employers, with or without the individual present;
e. On-the-job training in work skills required to perform the job;
f. Ongoing evaluation, supervision, and monitoring of the individual's performance on the job, which does not include supervisory activities rendered as a normal part of the business setting;
g. Ongoing support necessary to ensure job retention, with or without the individual present;
h. Supports to ensure the individual's health and safety;
i. Development of work-related skills essential to obtaining and retaining employment, such as the effective use of community resources, break or lunch areas, and transportation systems; and
j. Staff provision of transportation between the individual's place of residence and the workplace when other forms of transportation are unavailable or inaccessible. The job coach shall be present with the individual during the provision of transportation.
C. Service units and limits.
1. Providers shall be reimbursed only for the amount and type of supported employment included in the individual's plan for supports. The unit of service for individual supported employment shall be one hour, and the service shall be limited to 40 hours per week per individual. The unit of service for group supported employment shall be one hour, and the service shall be limited to 40 hours per week per individual.
2. Reimbursement for group supported employment service shall be based on the size of the group. Individual supported employment service shall be billed according to the DARS fee schedule.
3. Group and individual supported employment service alone or in combination with the community engagement service, community coaching service, workplace assistance service, or group day service shall not exceed 66 hours per week. Group [ and individual ] supported employment service shall take place in nonresidential settings separate from the individual's home.
4. For time-limited and service authorized periods (not to exceed 24 hours) individual supported employment service may be provided in combination with day service or residential service for purposes of [ job ] discovery [ under customized employment. Customized employment means a flexible process designed to personalize the employment relationship between a job candidate or employee and an employer in a way that meets the needs of both. It is based on identifying the strengths, conditions, and interests of a job candidate or employee through a process of discovery ].
5. Group and individual supported employment service shall include a skills development component along with the provision of supports, as needed.
6. Individual supported employment service can be provided simultaneously with the workplace assistance service to ensure that the workplace assistant is trained and appropriately supervised about supporting an individual through the best practices of individual supported employment.
a. Individual supported employment may be provided with workplace assistance (WPA) when the individual is nearing stability in his job and the [ employment specialist job coach ] will be transitioning the individual's [ case supports ] to the workplace assistance. Individual supported employment and workplace assistance may be provided concurrently for [ no more than three weeks prior to stability a limited time as defined in the individual's plan for supports in order to assure stability on the job site ].
b. Individual supported employment and WPA may also occur together for the purpose of follow along services as defined by DARS. During follow along, the job coach would oversee the plan implementation as well as continue to interface with the employment provider and the individual's systems to ensure continuity of employment services.
7. Individual ineligibility for supported employment service through DARS or IDEA shall be documented in the individual's record, as applicable. If the individual is ineligible to receive service through IDEA, documentation is required only for lack of DARS funding. Acceptable documentation for the lack of DARS or IDEA funding would include [ a letter from either DARS or the local school system or a record of a telephone call, including either written documentation from DARS or the school system or a progress note that records the content of a communication that includes a ] name, date, and person contacted, documented either in the individual's file maintained by the support coordinator, on the ISP, or [ on ] the supported employment provider's supporting documentation. Unless the individual's circumstances change, for example, the individual is seeking a new job, the original verification may be forwarded into the current record or repeated on the supporting documentation on an annual basis.
D. Provider requirements.
1 Providers shall meet all of the requirements set forth in 12VAC30-122-110 through 12VAC30-122-140.
2. Providers shall have a current, signed provider participation agreement with DMAS. The provider designated in this agreement shall directly provide the service and bill DMAS for reimbursement.
3. Providers shall be DARS-contracted providers of supported employment service. DARS shall verify that these providers meet criteria to be providers through a DARS-recognized accrediting body. DARS shall provide the documentation of this accreditation verification to DMAS and DBHDS upon request.
4. Providers shall maintain their accreditation in order to continue to receive Medicaid reimbursement. Providers who lose their accreditation, regardless of the reason, shall not be eligible to receive Medicaid reimbursement and shall have their provider agreements terminated by DMAS effective the same date as the date of the loss of accreditation. Reimbursements made to such providers after the date of the loss of the accreditation shall be subject to recovery by DMAS. Providers whose accreditation is restored shall be permitted to re-enroll with DMAS upon presentation of accreditation documentation and a new signed provider participation agreement.
[ As used in subdivisions 1 and 2 of this subsection, group supported employment service means continuous support provided by a job coach in a naturally occurring place of employment to groups of two to eight individuals with disabilities and involves interactions with the public and coworkers who do not have disabilities. This service shall be provided in a community setting that promotes integration into the workplace and interaction between participants and people without disabilities in the workplace. Examples include mobile crews and other business-based workgroups employing small groups of workers with disabilities in the community. ]
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. A copy of the completed, standard, age-appropriate assessment form as established in 12VAC30-122-200.
b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
c. Documentation [ confirming the individual's time in service and providing specific information regarding the individual's responses to various settings and supports. Observations of the individual's responses to service shall be available in at least a daily note. as detailed in 12VAC30-122-120. ] Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, then clearly documented in the progress notes or supports checklist.
d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.
e. A written review supported by documentation in the individuals' record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified. [ For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented. ]
f. [ Documentation that indicates the date, type of service rendered, and the number of hours provided, including specific timeframe. ] An attendance log or similar document [ that is shall be ] maintained [ and that indicates the date, type of service rendered, and the number of hours provided, including specific timeframe for group supported employment ].
g. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
h. Written documentation of contacts made with the [ individiual's individual's ] family/caregiver, physicians, providers, and all professionals concerning the individual.
i. Documentation of the size of the group [ for group supported employment ].
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-410. In-home support service.
A. Service description. In-home support service means a residential service that takes place in the individual's home, family home, or community settings that typically supplement the primary care provided by the individual, family, or other unpaid caregiver and is designed to ensure the health, safety, and welfare of the individual. The individual [ shall be enrolled in either the FIS or CL waiver and ] shall be living in his own home or his family home. This service shall include a skill building (formerly called training) component, along with the provision of supports that enable an individual to acquire, retain, or improve the self-help, socialization, and adaptive skills required for successfully living in his community. In-home support service shall be covered in the FIS and CL waivers.
B. Criteria and allowable activities. To be eligible for in-home support service, individuals shall require help with adaptive skills necessary to reside successfully in the home and community-based settings.
Allowable activities include the following as may be appropriate for the individual as documented in his plan for supports:
1. Skill-building and routine supports related to ADLs and IADLs;
2. Skill-building, routine supports, and safety supports related to the use of community resources, such as transportation, shopping, dining at restaurants, and participating in social and recreational activities;
3. Supporting the individual in replacing challenging behaviors with positive, accepted behaviors for home and community environments;
[ 4. Authorized to provide additional episodic supports when there is a change in the individual's routine schedule, such as the cancellation of work or a day activity because of a holiday or inclement weather, or support is required in accompanying an individual to a medical appointment. An estimate of the monthly requirement for episodic supports should be included in the initial authorization request. Authorized hours for episodic supports shall only be reimbursed when the service is rendered and supported by documentation.
5. 4. ] Monitoring the individual's health and physical condition and providing routine and safety supports with medication or other medical needs;
[ 6. 5. ] Providing supports with transportation to and from community sites and resources; and
[ 7. 6. ] Providing general supports as needed.
C. Service units and limitations.
1. The unit shall be one hour and shall be reimbursed according to the number of individuals served.
2. In-home support service shall not typically be provided 24 hours per day but may be authorized for brief periods up to 24 hours a day when [ medically ] necessary.
3. In-home support service shall not be covered for the individual simultaneously with the coverage of the group home residential service, supported living residential service, or sponsored residential service.
4. Individuals may have in-home support service, personal assistance service, and respite service in their ISP but shall not receive these Medicaid-reimbursed services simultaneously (i.e., on the same dates and times).
5. [ The individual shall have a back-up plan for times when in-home supports cannot occur as regularly scheduled. All individuals shall have a backup plan prior to initiating services in cases of emergency or should the provider be unable to render services as needed. This backup plan shall be shared with the provider and support coordinator at the onset of services and updated with the provider and support coordinator as necessary. ]
D. Provider qualifications and requirements.
1. All providers of the in-home support service shall have current, signed participation agreements with DMAS. The provider designated in this agreement shall directly submit claims to DMAS for reimbursement.
2. Providers of the in-home support service shall be licensed by DBHDS as providers of supportive in-home service.
3. Providers shall ensure that staff providing in-home supports meet provider [ competency ] training [ and competency ] requirements as specified in 12VAC30-122-180.
4. [ Supervision of direct support staff shall be provided by a supervisor meeting the requirements of 12VAC35-105. Documentation of supervision shall be completed, signed, and dated by the supervisor and shall include, at a minimum, the following: Supervision of DSPs shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight. ]
[ a. Date of contact or observation;
b. Person contacted or observed;
c. A summary about the direct support professional's performance and service delivery;
d. Any action planned or taken to correct problems identified during supervision and oversight; and
e. On a semiannual basis, observations documented by the supervisor concerning the individual's satisfaction with service provision. ]
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. A copy of the completed, standard, age-appropriate assessment form as described in 12VAC30-122-200.
b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
c. Documentation [ confirming the individual's amount of time in service and providing specific information regarding the individual's response to various settings and supports. as detailed in 12VAC30-122-120. ] Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, then clearly documented in the progress notes or supports checklist.
d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.
e. A written review supported by documentation in the individual's record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified. [ For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented. ]
f. An attendance log or similar document that is maintained and that indicates the date, type of service rendered, and the number of hours and units provided, including specific timeframe.
g. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
h. Written documentation of all contacts with the individual's family/caregiver, physicians, providers, and all professionals regarding the individual.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims that are not supported by appropriate documentation shall be subject to recovery by DMAS as a result of utilization reviews and audits.
12VAC30-122-420. Independent living support service.
A. Service description. Independent living support service means a service provided to adults 18 years of age and older that offers [ targeted ] skill building and supports necessary [ for individuals ] to secure and [ reside in an independent living situation in the community and ] maintain [ their own home in the ] community [ residence ]. An individual receiving this service typically lives alone or with roommates in the individual's own home or apartment. The supports may be provided in the individual's residence or in other community settings. Independent living support service shall be covered in the BI waiver.
B. Criteria and allowable activities. The need for independent living support service shall be clearly indicated in the ISP. Independent living support service shall be authorized for Medicaid reimbursement only when the individual requires this service and the service is set out in the plan for supports. This service shall include a skills development component along with the provision of supports as needed. Allowable activities include the following:
[ 1. Skill building and supports necessary to promote the individual's stability in the individual's own home and community in the absence of a primary caregiver living in the residence; ]
[ 1. 2. ] Skill-building and supports to promote the individual's community participation and inclusion in meaningful activities;
[ 2. 3. ] Skill-building and supports to increase [ the individual's ] socialization skills and maintain relationships;
[ 3. 4. ] Skill-building and supports to improve and maintain the individual's health, safety, and fitness, as necessary;
[ 4. 5. ] Skill-building and supports to promote the individual's decision-making and self-determination;
[ 5. 6. ] Skill-building and supports to improve and maintain, as needed, the individual's skills with ADLs and IADLs;
[ 6. 7. ] Routine supports with transportation to and from community locations and resources; and
[ 7. 8. ] General supports, as needed.
C. Service units and limits.
1. The independent living support service unit of service delivery shall be a month or, when beginning or ceasing the service, may be a partial month. Sufficient hours of service shall be provided to meet the requirements set forth in the plan for supports.
2. Independent living support service shall not be provided in a licensed residential setting.
3. Independent living support service is a tiered service for reimbursement purposes. Providers shall only be reimbursed for the individual's assigned level and tier.
D. Provider requirements.
1. Providers shall meet all of the requirements of 12VAC30-122-110 through 12VAC30-122-140.
2. Independent living support service shall be provided by agencies licensed by DBHDS as providers of supportive in-home service. These providers shall have a signed participation agreement with DMAS.
3. The provider designated on the agreement shall directly render this service and shall directly bill DMAS for reimbursement.
4. Providers shall ensure that staff providing independent living support service meet provider [ competency ] training [ and competency ] requirements as specified in 12VAC30-122-180.
5. [ A supervisor meeting the requirements of 12VAC35-105 shall provide supervision of direct support professional staff. Documentation of supervision shall be completed, signed, and dated by the supervisor who performs the supervision and oversight and shall include the following: Supervision of DSPs shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed, signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight. ]
[ a. Date of contact or observation;
b. Person contacted or observed;
c. A summary about the direct support professional's performance and service delivery;
d. Any action planned or taken to correct problems identified during supervision and oversight, and
e. Individual's satisfaction with the provision of service documented semiannually by the supervisor. ]
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. A copy of the completed, standard, age-appropriate assessment form as described in 12VAC30-122-200.
b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
c. Documentation [ confirming the individual's participation in service and providing specific information regarding the individual's responses to various settings and supports. as detailed in 12VAC30-122-120. ] Data shall be collected as described in the plan for supports, analyzed to determine if the strategies are effective, summarized, then clearly documented in the progress notes or supports checklist.
d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.
e. A written review supported by documentation in the individual's record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified. [ For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented. ]
f. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
g. Written documentation of contacts made with the individual's family/caregiver, physicians, providers, and all professionals concerning the individual.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-430. Individual and family/caregiver training service.
A. Service description. Individual and family/caregiver training service provides training and counseling to individuals, families, or caregivers of individuals enrolled in the waiver including participation in educational opportunities designed to improve the family's or caregiver's ability to care for and support the individual enrolled in the waiver. This service shall also provide educational opportunities for the individual to better understand his disability and increase his self-determination and self-advocacy. Individual and family/caregiver training service shall be covered in the FIS waiver.
B. Criteria and allowable activities.
1. Individuals who are enrolled in the FIS waiver and their family/caregivers, as appropriate, may participate in this service. DMAS shall cover this service as authorized by the individual's ISP.
2. For the purpose of this service, "family" means the [ unpaid people who live with or provide care to an individual served in the waiver and may include a parent, a guardian, a spouse, children, relatives, a foster family, or in-laws but shall not include persons who are compensated, by any possible means, to care for the individual. same as set forth in 12VAC30-122-20. ]
C. Service units and limits.
1. Individual and family/caregiver training service is only available in the FIS waiver.
2. Individual and family/caregiver training service may be authorized for up to $4,000 per ISP year.
3. Travel expenses and room and board expenses shall not be covered.
D. Provider requirements.
1. Providers shall meet all of the requirements of 12VAC30-122-110 through 12VAC30-122-140.
2. Providers shall have a signed, current provider participation agreement with DMAS in order to be reimbursed for providing individual and family/caregiver training.
3. Providers shall have the necessary licensure or certification as required for their profession, that is, RNs shall have a current license to practice nursing in the Commonwealth or shall hold a multistate licensure privilege.
4. Individual and family/caregiver training service shall be provided by enrolled provider entities with expertise in, experience in, or demonstrated knowledge of the training topic set out in the plan for supports.
5. Individual and family/caregiver training service may be provided through seminars and conferences organized by the enrolled provider entities.
6. Individual and family/caregiver training service may also be provided by individual practitioners who have experience in or demonstrated knowledge of the training topics. Individual practitioners may include psychologists, teachers or educators, social workers, medical personnel, personal care providers, therapists, and providers of other services such as day and residential support services.
7. Qualified provider types include:
a. Staff of home health agencies, community developmental disabilities service agencies, developmental disabilities residential providers, community mental health centers, public health agencies, hospitals, clinics, or other agencies or organizations; and
b. Individual practitioners, including licensed or certified personnel such as RNs, LPNs, psychologists, speech-language therapists, occupational therapists, physical therapists, licensed clinical social workers, licensed behavior analysts, and persons with other education, training, or experience directly related to the specified needs of the individual as set out in the ISP.
E. Service documentation and requirements.
1. The support coordinator shall maintain a plan for supports that includes:
a. Identifying information such as provider name, provider number, responsible person and telephone number, effective dates for the service, and if applicable, person-centered review dates;
b. Expected outcomes of the training; and
c. Specific training or activities showing frequency, location, dates and times, and to whom the training was provided.
2. The provider shall maintain and relay to the support coordinator contact notes or a summary documenting:
a. Date, location, hours, and summary of each training event;
b. Plan for support desired outcome that was addressed;
c. Specific details of the training activities conducted, including person to whom activities were directed;
d. Training delivered as planned or modified; and
e. Effectiveness of strategies and satisfaction of the individual or family member/caregiver.
3. Person-centered reviews by the provider (i) shall be required quarterly if the training extends three months or longer, (ii) shall be forwarded to the support coordinator, and (iii) shall include:
a. A summary of the quarter's activities;
b. Training recipient's status and satisfaction with the service; and
c. Training outcomes and effectiveness.
4. Provider and support coordinator documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-440. [ Nonmedical Employment and community ] transportation service [ (Reserved.) ].
[ A. Service description. This service is offered in order to enable individuals to gain access to an individual's place of employment or volunteer activity, other community services or events, activities and resources, homes of family or friends, civic organizations or social clubs, public meetings or other civic activities, and spiritual activities or events as specified by the support plan and when no other means of access is available. The goal of this service is to promote the individual's independence and participation in the life of the individual's community. Use of this service shall be related to the individual's desired outcomes as stated in the ISP. This service is offered in addition to medical transportation required under 42 CFR 431.53 and transportation services under the State Plan, defined at 42 CFR 440.170(a), and does not replace them.
B. Criteria and allowable activities.
1. The service may include transportation in a private vehicle by a person such as a coworker or other community member or the purchase of tickets for public transportation such as bus or subway. In either case, an administering agency shall coordinate and bill DMAS.
2. Up to three individuals may be transported in a single, private vehicle per trip.
3. The administering agency will ensure that pertinent information about the individual is relayed to the driver.
C. Service units and limitations.
1. This service shall not be authorized or reimbursed for individuals who can access transportation through the State Plan or other waiver services that include a transportation component. The individual or legal guardian shall attest that he does not have sufficient personal financial resources (e.g., through wages) to cover the cost of the transportation himself.
2. Private transportation is reimbursed according to a "trip," which is reimbursed for the round-trip, and the number of individuals being transported to the location (maximum of three). There are three trip rates depending on the one-way distance traveled:
a. Less than 10 miles.
b. Between 10 and 20 miles.
c. Over 20 miles.
3. When a private driver is transporting more than one individual to a single destination, the trip rate for all individuals is the same and is determined by the distance between the first individual picked up and the final destination.
4. The purchase of tickets for public transportation and dissemination to the individual is coordinated by the administering agency.
5. A provider delivering other waiver services to an individual may not utilize staff to provide Employment and community transportation (ECT) and may only bill ECT if the transportation would not be a normally required element of service provision.
D. Provider qualifications and requirements.
1. The service may be provided by the individual's family member or legally responsible person, but may not be the guardian, parent, step-parent of an individual younger than 18 years of age, or spouse of an adult who is receiving the service.
2. The service shall be offered through an administering agency that possesses any DBHDS license to provide services to individuals with developmental disabilities, an employment service organization, or a center for independent living. Administering agencies shall be enrolled with DMAS through a participation agreement, to provide these services.
3. In the case of private transportation, the administering agency shall be responsible for screening community persons to drive the individual to designated locations according to the ISP.
4. The private driver shall:
a. Be 18 years of age or older;
b. Possess a valid driver's license; and
c. Possess and maintain at a minimum:
(1) A satisfactory driving record defined as no reckless driving charges within the past 24 months, and
(2) Proof of general liability insurance coverage in compliance with federal or state statutory requirements The insurance shall insure the driver or the passengers (i) against loss from any liability imposed by law for damages; (ii) against damages for care and loss of services because of bodily injury to or death of any person; (iii) against injury to or destruction of property caused by accident and arising out of the ownership, use, or operation of such motor vehicle within the Commonwealth, any other state in the United States, or Canada; (iv) subject to a limit or exclusive of interest and costs, with respect to each motor vehicle of $25,000 because of bodily injury to or death of one person in any one accident and, subject to the limit for one person, to a limit of $50,000 because of bodily injury to or death of two or more persons in any one accident; and (v) subject to a limit of $20,000 because of injury to or destruction of property of others in any one accident.
5. The administering agency shall be responsible for screening community persons to drive the individual to designated locations according to the ISP. This includes verification of the private driver's:
a. Possession of a current, valid driver's license and no reckless driving charges within the past 24 months;
b. Possession of car insurance;
c. Ensuring that the driver meets the minimum age requirement of age 18; and
d. Completion of an attestation signed by the private driver, the individual, and the individual's guardian or authorized representative, as appropriate, that the driver has disclosed any relevant felonies and if listed on any registry. The administering agency shall ensure that the driver is not listed on the Virginia Sex Offender Registry.
6. Initially and annually the administering provider shall verify and document that each private driver possesses a current, valid driver's license, and car insurance.
E. Documentation requirements for service providers.
1. Providers shall include in each individual's record:
a. A copy of the completed, standard, age-appropriate assessment form as described in 12VAC30-122-200.
b. The provider's plan for supports in the form of the ECT Trip Plan form.
c. Documentation of the trip distance estimate in the form of a MapQuest, Google Maps, or similar printout with point of origin, destination, and mileage.
d. Documentation to support units of service delivered in the form of a monthly trip log signed by the individual recording trips taken that shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.
e. A written review, supported by documentation in the individual's record, shall be submitted to the support coordinator quarterly, during any quarters in which the service was provided and if modified, with the plan for supports. This written review shall list the dates and destinations of trips taken and a statement about the individual's satisfaction with the service.
f. For private drivers, (i) copies of valid drivers' licenses, (ii) copies of the automobile insurance policies, (iii) copies of driving records, and (iv) criminal records attestations and Virginia Sex Offender Registry record checks. The driver is responsible for notifying the agency if there are any changes to previously submitted attestations or significant driving record changes, versus requiring the agency to have to obtain these every year (or whatever time period).
g. For public transportation, receipts for purchases of bus tickets, or fare cards.
h. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
i. Written documentation of all contacts with family/caregiver, physicians, formal and informal service providers, and all professionals regarding the individual.
j. The written attestation by the individual or legal guardian that the individual does not have sufficient personal financial resources (e.g., through wages) to cover the cost of the transportation himself.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims that are not supported by appropriate documentation shall be subject to recovery by DMAS as a result of utilization reviews and audits. ]
12VAC30-122-450. Peer support service [ (Reserved.) ].
[ A. Service description. Peer mentor supports provide information, resources, guidance, and support from an experienced, trained peer mentor to an individual who is a waiver recipient. This service is delivered to waiver recipients by other individuals with developmental disabilities who are or have been service recipients, have shared experiences with the individual, and provide support and guidance to him. The service is designed to foster connections and relationships that build individual resilience. Peer mentor supports encourage individuals with developmental disabilities to share their successful strategies and experiences in navigating a broad range of community resources beyond those offered through the waiver with waiver participants so that the waiver participant is better able to advocate for and make a plan to achieve integrated opportunities and experiences in living, working, socializing, and staying healthy and safe in his own life, as well as to overcome personal barriers which are inhibiting him from being more independent. Peer mentoring is intended to assist with empowering the individual receiving the service. This service is delivered based on the support needs of the individual as outlined in his person-centered plan. This service shall require the use of a peer support service administrative provider enrolled with DMAS that shall be responsible for directly coordinating the service and directly billing DMAS for reimbursement. This service is designed to be short-term and periodic in nature.
B. Criteria and allowable activities. Allowable activities may include the following for the individual as documented in the individual's plan for supports:
1. The administering agency facilitates peer to peer "matches" and follows up to ensure the matched relationship meets the individual's expectations;
2. The peer mentor has face-to-face contact with the individual to discuss the individual's specific interests or desired outcomes related to realizing greater independence and the barriers to achieving them;
3. The peer mentor explains community services and programs and suggests strategies to the individual to achieve the individual's desired outcomes, particularly related to living more independently, engaging in paid employment, and expanding social opportunities in order to reduce the need for supports from family members or paid staff;
4. The peer mentor provides information from his experiences to help the individual in problem solving, decision making, developing supportive community relationships, and exploring specific community resources that promote increased independence and community integration; or
5. The peer mentor assists the individual in developing a personal plan for accessing the identified integrated community activities, supports, services, or resources.
C. Service units and limitations.
1. Peer mentor supports is expected to be a short, periodically intermittent, intense service associated with a specific outcome. Peer mentor supports may be authorized for up to six consecutive months, and the cumulative total across that timeframe may be no more than 60 hours in a plan year.
2. The peer mentor shall not supplant, replace, or duplicate activities that are required to be provided by the support coordinator. Prior to accessing funding for this waiver service, all other available and appropriate funding sources shall be explored and exhausted.
3. Peer mentors cannot mentor their own family members.
4. Peer mentors shall be at least 21 years of age and may provide these supports only to individuals 16 years of age and older.
5. Individuals who receive supports through DD Waiver or other waivers may be peer mentors.
D. Provider qualifications and requirements.
1. The administering agency shall be a DBHDS licensed provider of DD Waiver services, employment service organization, or center for independent living. The administering agency shall serve as the enrolled provider and maintain the documentation of the peer mentor's qualifications, criminal background and Child Protective Registry (if service recipient is younger than 18 years of age) checks, and other required documentation.
2. Peer mentor supports shall be provided by an individual with a developmental disability who has lived independently in the community for at least one year and is or has been a recipient of services, including to publicly-funded housing, Medicaid waiver services, work incentives, and supported employment.
3. The peer mentor shall have completed DBHDS's DD Peer Mentor training curriculum and passed the accompanying test.
4. The peer mentor supports administering agency shall have a signed provider participation agreement with DMAS.
E. Documentation requirements for service providers.
1. Providers shall include in each individual's record:
a. A copy of the completed, standard, age-appropriate assessment form as described in 12VAC30-122-200.
b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
c. Documentation which shall confirm the individual's amount of time in services, a log of contacts, and information regarding the type of supports delivered to the individual.
d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.
e. A written review supported by documentation in the individual's record shall be submitted to the support coordinator quarterly, during any quarters in which the service was provided, with the plan for supports, if modified. This written review shall list the dates and nature of contacts and a statement about the individual's satisfaction with the service.
f. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
g. Written documentation of all contacts with family/caregiver, physicians, formal and informal service providers, and all professionals regarding the individual.
h. Documentation of the peer mentor's qualifications, as well as criminal background and Child Protective Registry (if service recipient is younger than 18 years of age) checks.
2. Administering agency documentation shall support all claims submitted for DMAS reimbursement. Claims that are not supported by appropriate documentation shall be subject to recovery by DMAS as a result of utilization reviews and audits. ]
12VAC30-122-460. Personal assistance service.
A. Service description. Personal assistance service may be provided either through an agency-directed or a consumer-directed model.
1. Personal assistance service means direct support [ or supervision ] with (i) ADLs, (ii) IADLs, (iii) access to the community, (iv) monitoring the self-administration of medication or other medical needs, (v) monitoring health status and physical condition, or (vi) work or postsecondary school-related personal assistance. Personal assistance service substitutes for the absence, loss, diminution, or impairment of a physical, behavioral, or cognitive function.
2. When specified in the plan for supports, personal assistance service may include assistance with IADLs. Assistance with IADLs shall be documented in the plan for supports as essential to the health and welfare of the individual, rather than for the individual's family/caregiver's comfort or convenience, or both. In order to be approved for IADL support, the individual shall also require ADL supports.
3. An additional component to personal assistance service is work personal assistance or postsecondary school-related personal assistance that allows the personal assistance service provider to provide assistance and supports to individuals in the workplace and postsecondary educational institutions. Work-related personal assistance service shall not duplicate supported employment service. [ Personal assistance can be provided simultaneously with supported employment services and can be billed concurrently. ]
4. Personal assistance service shall be covered in the FIS and CL waivers.
B. Criteria and allowable activities.
1. To qualify for personal assistance service, the individual shall demonstrate a need for assistance with ADLs, [ reminders to take support with taking ] medication [ , ] or other medical needs, or monitoring health status or physical condition.
2. Individuals may receive both agency-directed and consumer-directed personal assistance as long as the two service models do not overlap the same days and times.
3. Individuals choosing the consumer-directed option for personal assistance service may receive support from a services facilitator and shall meet requirements for consumer direction as described in 12VAC30-122-150.
4. For personal assistance service, allowable activities shall include:
a. Support with ADLs;
b. Support with monitoring of health status or physical condition;
c. Support with prescribed use of medication and other medical needs;
d. Support with preparation and eating of meals;
e. Support with housekeeping [ actitivities activities ], such as bed-making, cleaning, or the individual's laundry;
f. Support with participation in social, recreational, and community activities;
g. Assistance with bowel/bladder care needs, range of motion activities, routine wound care that does not include the sterile technique, and external catheter care when [ trained and ] supervised by an RN;
h. Accompanying the individual to appointments or meetings; and
i. Safety supports. [ For a child younger than 18 years of age the Request for Supervision Hours in Personal Assistance form, DMAS P-257, shall be submitted for service authorization purposes when supervision hours are requested to address safety support needs. ]
C. Service units and limits.
1. The unit of service for personal assistance service shall be one hour. The hours to be authorized shall be based on the individual's assessed and documented need as reflected in the plan for supports.
2. Any combination of respite service, personal assistance service, and companion service in the consumer-directed service model shall be limited to 40 hours per week for an employer of record (EOR) by the same assistant. Assistants who live with the individual, either full time or for substantial amounts of time, shall not be restricted to only 40 hours per week for the EOR. [ CD services employees shall work no more than 16 hours per day. ]
3. Individuals may receive a combination of personal assistance service, respite service, [ companion, ] and in-home support service as documented in their ISPs but shall not simultaneously receive in-home supports service, personal assistance service, or respite service.
4. Individuals shall require assistance with ADLs in order to receive IADL care through personal care service.
5. An individual shall be permitted to share personal assistance service hours with one other individual who is also receiving waiver-covered personal assistance service and who also lives in the same home [ , however, the number of hours billed shall not exceed the number of hours the assistant worked ].
6. Personal assistance service shall not include skilled nursing (neither practical nor professional nursing) service with the exception of skilled nursing tasks that are delegated in accordance with 18VAC90-19-240 through 18VAC90-19-280. [ Skilled nursing services can be performed as allowed by § 54.1-2901 A 31 of the Code of Virginia. ]
7. Persons rendering personal assistance service for reimbursement by DMAS shall not be the individual's spouse. If the individual is a minor child, service shall not be reimbursed if the service is provided by his parent or guardian.
a. Family members who are approved to be reimbursed by DMAS to provide [ companion personal assistance ] service shall meet all of the [ companion assistance ] qualifications.
b. [ Companion Personal assistance ] service shall not be provided by adult foster care providers or any other paid caregivers for an individual residing in that foster care home.
8. Work personal assistance or postsecondary school-related personal assistance shall not be provided if they should be provided by DARS or under IDEA, or if they are an employer's responsibility under the Americans with Disabilities Act (42 USC § 12101 et seq.), the Virginians with Disabilities Act (Title 51.5 (§ 51.5-1 et seq.) of the Code of Virginia), or § 504 of the Rehabilitation Act (42 USC § 701 et seq.).
9. Personal assistance shall not be reimbursed by DMAS for individuals who receive group home residential service, sponsored residential service, or supported living residential service; who live in assisted living facilities; or who receive comparable services from another program, service, or payment source, except as noted in subdivision A 3 of this section.
[ 10. Personal assistance service shall not be covered under the waiver if the individual who is younger than 21 years of age is eligible for personal assistance service through Medicaid's Early and Periodic Screening, Diagnosis and Treatment program (12VAC30-50-130). ]
D. Provider requirements.
1. Providers shall meet all of the requirements of 12VAC30-122-110 through 12VAC30-122-140.
2. For agency-directed personal assistance service, the provider shall be licensed by DBHDS as either a group home provider, residential provider, or supportive in-home residential provider or shall meet the VDH licensing requirements or have accreditation from a CMS-recognized organization to be a personal care or respite care provider.
3. Providers of personal assistance service shall have a current, signed participation agreement with DMAS. Providers as designated on this agreement shall render this service directly and shall bill DMAS directly for Medicaid reimbursement.
4. Supervision requirements for agency-directed personal assistance service.
a. A supervisor shall provide ongoing supervision of all personal assistants.
b. For personal assistance service providers that are licensed by DBHDS, a supervisor meeting the requirements of [ 12VAC35-105 12VAC35-105-590 ] shall provide supervision of direct support professional staff.
c. For personal assistance service providers that are licensed by the Virginia Department of Health (VDH), the provider shall employ or subcontract with and directly supervise an RN or an LPN who shall provide ongoing supervision of all assistants. The supervising RN or LPN shall have at least one year of related clinical nursing experience that may include work in an acute care hospital, public health clinic, home health agency, ICF/IID, or nursing facility.
d. The supervisor shall make a home visit to conduct an initial assessment prior to the start of service for all individuals enrolled in the waiver requesting and who have been approved to receive personal assistance. The supervisor shall also perform any subsequent reassessments or changes to the plan for supports. All changes that are indicated for an individual's plan for supports shall be reviewed with and agreed to by the individual and, if appropriate, the individual's family/caregiver.
e. The supervisor shall make supervisory home visits as often as needed to ensure both quality and appropriateness of the service. The minimum frequency of these visits shall be every 30 to 90 days under the agency-directed model, depending on the individual's needs.
f. Based on continuing evaluations of the assistant's performance and the individual's needs, the supervisor shall identify any gaps in the assistant's ability to function competently and shall provide training as indicated.
5. Service facilitation requirements for the personal assistance service shall be the same as those set forth in 12VAC30-122-150.
6. [ The provider of personal assistance shall have a back-up plan in case the personal assistant does not report for work as expected or terminates employment without prior notice. All individuals shall have a backup plan prior to initiating services in cases of emergency or should the provider be unable to render services as needed. This backup plan shall be shared with the provider and support coordinator at the onset of services and updated with the provider and support coordinator as necessary. ]
[ 7. In the consumer-directed model, the individual, EOR, or family/caregiver shall also have a back-up plan in case the personal assistant does not report for work as expected or terminates employment without prior notice.
8. 7. ] Requirements for agency-directed assistants.
a. Providers shall ensure that staff providing the personal assistance service meet provider [ competency ] training [ and competency ] requirements as specified in 12VAC30-122-180.
b. Assistants employed by personal assistance agencies licensed by VDH shall have completed an educational curriculum of at least 40 hours of study related to the needs of individuals who have disabilities, including intellectual and developmental disabilities. The provider shall ensure, prior to assigning assistants to support an individual, that the assistants have the required skills and training to perform the service as specified in the individual's plan for supports and related supporting documentation. Assistants' required training shall be met in one of the following ways:
(1) Registration with the Board of Nursing as a certified nurse aide;
(2) Graduation from an approved educational curriculum as listed by the Board of Nursing; or
(3) Completion of the provider's educational curriculum, as conducted by a licensed RN who shall have at least one year of related clinical nursing experience that may include work in an acute care hospital, public health clinic, home health agency, ICF/IID, or nursing facility.
c. Assistants shall have a satisfactory work record, as evidenced by two references from prior job experiences, if applicable, including no evidence of possible abuse, neglect, or exploitation of elderly persons, children, or adults with disabilities.
d. Provider inability to render the service and substitution of assistants. When assistants are absent or otherwise unable to render scheduled supports to individuals enrolled in the waiver, the provider shall be responsible for ensuring that the service continues to be provided to the affected individuals.
(1) The provider may either obtain a substitute assistant from another provider if the lapse in coverage is to be less than two weeks in duration or transfer the individual's services to another personal assistance service provider. [ The provider who holds the service authorization to provide service to the individual enrolled in the waiver shall contact the support coordinator to determine if additional or modified service authorization is necessary. ]
(2) If no other provider is available who can supply a substitute assistant, the provider shall notify the individual and the individual's family/caregiver, as appropriate, and the support coordinator so that the support coordinator may find another available provider of the individual's choice.
(3) During temporary, short-term lapses in coverage that are not expected to exceed approximately two weeks in duration, the following procedures shall apply:
(a) The service-authorized provider shall provide the supervision for the substitute assistant;
(b) The provider of the substitute assistant shall send a copy of the assistant's daily documentation signed by the assistant, the individual, and the individual's family/caregiver, as appropriate, to the provider having the service authorization; and
(c) The service authorized provider shall bill DMAS for service rendered by the substitute assistant.
e. If a provider secures a substitute assistant, the provider agency shall be responsible for ensuring that all DMAS requirements continue to be met including documentation of service rendered by the substitute assistant and documentation that the substitute assistant's qualifications meet DMAS requirements. The two providers involved shall be responsible for negotiating the financial arrangements of paying the substitute assistant.
[ 8. Persons functioning as assistants shall meet the following requirements:
a. Be at least 18 years of age;
b. Be able to read and write English to the degree required to function in this capacity and create and maintain the required documentation to support billing and possess basic math skills;
c. Be capable of following a plan for supports with minimal supervision and physically able to perform the required work;
d. Possess a valid Social Security Number that has been issued by the Social Security Administration to the person who is to function as the assistant;
e. Be capable of aiding in IADLs;
f. Receive a tuberculosis screening according to the requirements of the Virginia Department of Health; and
g. For consumer directed assistants, be willing to attend training at the individual's or family/caregiver's request. ]
E. Agency-directed service documentation and requirements.
1. The record for agency-directed providers shall at a minimum contain [ all of the following ]:
a. The most recently updated plan for supports and supporting documentation, and all provider documentation [ ;. ]
b. A copy of the most recently updated age-appropriate assessment form as set out in 12VAC30-122-200, the initial assessment by the DBHDS-licensed agency supervisor or RN supervisory nurse completed prior to or on the date the service is initiated, subsequent reassessments, and changes to the supporting documentation by the RN supervisory nurse [ ;. ]
c. Supervisor's summarizing notes recorded and dated during any contacts with the personal assistant during supervisory visits to the individual's home [ ;. ]
d. The specific service delivered to the individual enrolled in the waiver by the personal assistant dated the day of service delivery, and the individual's unique, specific responses [ ;. ]
e. The personal assistant's arrival and departure times [ ;. ]
f. The personal assistant's weekly comments or observations about the individual enrolled in the waiver to include individual-specific observations of the individual's physical and emotional condition, daily activities, and responses to the service [ ;. ]
g. The personal assistant's, individual's and the individual's family/caregiver's, as appropriate, weekly signatures recorded on the last day of service delivery for any given week to verify that the personal assistance service during that week has been rendered [ ;. ]
h. A written review supported by documentation in the individuals' record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified [ ;. For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented. ]
i. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS [ ; and. ]
j. Written documentation of all contacts with the individual's family/caregiver, physicians, providers, and all professionals regarding the individual.
2. Personal assistant service records shall be separated from those of other nonwaiver services, such as home health service.
3. Provider progress notes shall meet the standards contained in 12VAC30-122-120 A.
4. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
F. Consumer-directed documentation requirements are set forth in 12VAC30-122-500 E.
12VAC30-122-470. Personal emergency response system service.
A. Service description. Personal emergency response system (PERS) service is an electronic device and monitoring service that enables certain individuals to secure help in an emergency. PERS service shall be limited to those individuals who live alone or are alone for significant parts of the day and who have no regular caregiver for extended periods of time and who would otherwise require supervision. PERS service shall be covered in the FIS, CL, and BI waivers.
B. Criteria. PERS may be authorized when there is no one else in the home with the individual enrolled in the waiver who is competent or continuously available to call for help in an emergency.
C. Service units and service limitations.
1. The one-time installation of the unit shall include installation, account activation, individual and caregiver instruction, and removal of PERS equipment. A unit of service is the one-month rental price set by DMAS.
2. PERS service shall be capable of being activated by a remote wireless device and shall be connected to the individual's telephone system. The PERS console unit shall provide hands-free voice-to-voice communication with the response center. The activating device shall be waterproof, automatically transmit to the response center an activator low battery alert signal prior to the battery losing power, and be able to be worn by the individual.
3. PERS service shall not be used as a substitute for providing adequate supervision for the individual enrolled in the waiver.
4. Physician-ordered medication monitoring units shall be provided simultaneously with PERS service.
5. PERS service shall not be covered for individuals who are simultaneously receiving group home residential service, sponsored residential service, or supported living residential service.
D. Provider requirements.
1. Providers shall meet all requirements of 12VAC30-122-110 through 12VAC30-122-140.
2. Providers shall be either a (i) licensed home health or personal care agency, (ii) a durable medical equipment provider, (iii) a hospital, or (iv) a PERS manufacturer that has the ability to provide PERS equipment, direct services (i.e., installation, equipment maintenance, and service calls), and PERS monitoring.
3. Providers shall have a current, signed provider participation agreement with DMAS. This agreement shall be renewed promptly when requested by DMAS. The provider named on the participation agreement shall directly render the PERS service and shall submit his claims to DMAS for reimbursement.
4. Providers shall provide an emergency response center staff with fully trained operators who are capable of (i) receiving signals for help from an individual's PERS equipment 24 hours a day, 365 or 366, as appropriate, days per year; (ii) determining whether an emergency exists; and (iii) notifying an emergency response organization or an emergency responder that the individual needs emergency help.
5. Providers shall comply with all applicable federal and state laws and regulations, all applicable regulations of DMAS, and all other governmental agencies having jurisdiction over the service to be performed.
6. Providers shall have the primary responsibility to furnish, install, maintain, test, and service the PERS equipment, as required to keep it fully operational. The provider shall replace or repair the PERS device within 24 hours of the individual's or family/caregiver's notification of a malfunction of the console unit, activating devices, or medication-monitoring unit while the original equipment is being repaired.
7. Providers shall properly install all PERS equipment into the functioning telephone line or cellular system of an individual receiving PERS and shall furnish all supplies necessary to ensure that the system is installed and working properly.
8. The PERS installation shall include local seize line circuitry, which guarantees that the unit will have priority over the telephone connected to the console unit should the phone be off the hook or in use when the unit is activated.
9. Providers shall install, test, and demonstrate to the individual and the individual's family/caregiver, as appropriate, the PERS system before submitting the claim for reimbursement to DMAS.
10. Providers shall maintain all installed PERS equipment in proper working order.
11. Providers shall maintain a data record for each individual receiving PERS service at no additional cost to DMAS. The record shall document all of the following:
a. Delivery date and installation date of the PERS;
b. The signature of the individual or the individual's family/caregiver, as appropriate, verifying receipt of PERS device;
c. Verification by a test that the PERS device is operational, monthly or more frequently as needed;
d. Updated and current individual responder and contact information, as provided by the individual or the individual's care provider, or support coordinator/case manager; and
e. A case log documenting the individual's utilization of the system and contacts and communications with the individual or the individual's family/caregiver, as appropriate, support coordinator/case manager, or responder.
12. Providers shall have back-up monitoring capacity in case the primary system cannot handle incoming emergency signals.
13. All PERS equipment shall be approved by the Federal Communications Commission and meet the Underwriters' Laboratories, Inc. (UL) safety standard Number 1635 for Digital Alarm Communicator System Units and Number 1637, which is the UL safety standard for home health care signaling equipment. The UL listing mark on the equipment will be accepted as evidence of the equipment's compliance with such standard. The PERS device shall be automatically reset by the response center after every activation ensuring that subsequent signals can be transmitted without requiring manual reset by the individual enrolled in the waiver or family/caregiver, as appropriate.
14. Providers shall instruct the individual, his family/caregiver, as appropriate, and responders in the use of the PERS.
15. The emergency response activator shall be activated either by breath, by touch, or by some other means and shall be usable by persons who have visual or hearing impairments or physical disabilities. The emergency response communicator shall be capable of operating without external power during a power failure at the individual's home for a minimum period of 24 hours and automatically transmit a low battery alert signal to the response center if the back-up battery is low. The emergency response console unit shall also be able to self-disconnect and redial the back-up monitoring site without the individual resetting the system in the event the unit cannot get its signal accepted at the response center.
16. Monitoring agencies shall be capable of continuously monitoring and responding to emergencies under all conditions, including power failures and mechanical malfunctions. The provider is responsible for ensuring that the monitoring agency and the agency's equipment meet the requirements of this section. The monitoring agency shall be capable of simultaneously responding to multiple signals for help from multiple individuals' PERS equipment. The monitoring agency's equipment shall include the following:
a. A primary receiver and a back-up receiver, which shall be independent and interchangeable;
b. A back-up information retrieval system;
c. A clock printer, which shall print out the time and date of the emergency signal, the PERS individual's identification code, and the emergency code that indicates whether the signal is active, passive, or a responder test;
d. A back-up power supply;
e. A separate telephone service;
f. A toll-free number to be used by the PERS equipment in order to contact the primary or back-up response center; and
g. A telephone line monitor, which shall give visual and audible signals when the incoming telephone line is disconnected for more than 10 seconds.
17. The monitoring agency shall maintain detailed technical and operations manuals that describe PERS service elements, including the installation, functioning, and testing of PERS equipment; emergency response protocols; and recordkeeping and reporting procedures.
18. Providers shall document and furnish within 30 calendar days of the action taken a written report to the support coordinator/case manager for each emergency signal that results in action being taken on behalf of the individual. This excludes test signals or activations made in error.
E. Service documentation and requirements:
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. [ A plan for supports as detailed in 12VAC30-122-120. ] The appropriate service authorization to be completed by the support coordinator may serve as the plan for supports for the provision of PERS service. A rehabilitation engineer may be involved for PERS service if disability expertise is required that a general contractor may not have. The plan for supports and service authorization shall include justification and explanation if a rehabilitation engineer is needed. The service authorization request shall be submitted to the state-designated agency or its designee in order for service authorization to occur;
b. For PERS service, written documentation regarding the process and results of ensuring that the item is not covered by the State Plan for Medical Assistance as durable medical equipment (DME) and supplies, and that the item is not available from a DME provider;
c. Documentation of the recommendation for the item by an independent professional consultant and the amount of service that is needed;
d. Documentation of the date the service is rendered;
e. Any other relevant information regarding the device or modification;
f. Documentation in the support coordination record of notification by the designated individual or the individual's representative or family/caregiver of satisfactory completion or receipt of the service or item; and
g. Instructions regarding any warranty, repairs, complaints, or servicing that may be needed.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-480. Private duty nursing service.
A. Service description. Private duty nursing (PDN) service means individual and continuous nursing care that [ may shall ] be provided [ , concurrently with other services, ] due to the intensity of medical supports required by individuals who have complex health care needs that have been certified by a physician as medically necessary to enable the individual to remain at home rather than in a hospital, nursing facility, or ICF/IID. [ PDN service shall be rendered to the individual in his residence or other community settings. PDN shall be provided on a one-to-one basis, and cannot be provided concurrently with skilled nursing services, personal assistance services, respite services, or companion services. Individuals receiving PDN services shall not be authorized for skilled nursing services except in the case of nurse delegation responsibility activities. PDN shall support and not replace caregiver responsibilities. ] PDN service shall be covered in the FIS and CL waivers.
B. Criteria and allowable activities.
1. The individual shall require PDN service that has been certified by a Virginia-licensed physician as medically necessary to enable the individual to remain at home or otherwise in the community rather than in a hospital, a nursing facility, an ICF/IID, or any other type of institution.
2. The medical necessity for PDN service shall be documented in the individual's ISP. Once the medical necessity can no longer be demonstrated, this service shall be terminated.
3. Allowable activities shall include:
a. [ Monitoring On-going monitoring ] of an individual's medical status [ as it relates to the specified medical and nursing needs ];
b. Administering medications or other medical treatment; and
[ c. Training of family and other caregivers, for up to 30 days after an acute care episode or new diagnosis that requires regular intervention by caregivers. Assistance with ADLs in conjunction with medical treatment and care.
d. Training for family or other caregivers in relation to those activities that are part of the nursing plan for supports. ]
C. Service units and limits.
1. The unit of service shall be a quarter hour.
2. Individuals enrolled in the waiver shall not be authorized to receive private duty nursing service [ during the same authorized period as with and ] skilled nursing service.
3. Private duty nursing service shall not be covered under the waiver if the individual who is younger than 21 years of age is eligible for private duty nursing service covered through Medicaid's Early and Periodic Screening, Diagnosis and Treatment program.
D. Provider requirements.
1. Providers shall meet all of the requirements set out in 12VAC30-122-110 through 12VAC30-122-140.
[ 2. If the provider designated in the participation agreement employs LPNs to render direct care, then the provider shall also employ an RN or be an RN himself in order to supervise the LPNs.
3. 2. ] Private duty nursing service may be provided by either (i) a licensed RN or (ii) licensed LPN who is under the supervision of a licensed RN. The licensed RN or LPN shall be employed by a DMAS-enrolled home health provider or contracted with or employed by a DBHDS-licensed day support service, respite service, or residential service provider.
[ 4. 3. ] Both RNs and LPNs providing private duty nursing service shall have current licenses issued by the Virginia Board of Nursing or hold current multistate licensure privileges to practice nursing in the Commonwealth.
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. A copy of the completed, standard, age-appropriate assessment form as described in 12VAC30-122-200.
b. The provider's plan for supports per requirements detailed in 12VAC30-122-120 [ and the CMS 485 ].
c. Documentation of all training, including the dates and times provided to family/caregivers or staff, or both, including the person being trained and the content of the training. [ Training of professional staff shall be consistent with the Regulations Governing the Practice of Nursing (18VAC90-19). ]
d. Documentation that the RN and LPN has the experience or skills necessary to perform the tasks [ as ordered by the physician included ] in the plan for supports.
e. Documentation of nursing licenses [ and, ] qualifications of providers [ , and physician's orders done every six months ].
f. Documentation of the physician's determination of medical necessity prior to service being rendered.
g. [ Documentation indicating the dates and times that this service is provided and the amount and type of nursing interventions provided. Documentation summarizing interventions, results of treatment, the dates and times of nursing interventions that are provided, and the amount and type of service. ]
h. A review of the supporting documentation with the individual or his family/caregiver, as appropriate, and documentation that shows a written summary of this review was submitted to the support coordinator/case manager at least quarterly with the plan for supports modified as appropriate. For the annual review and anytime supporting documentation is updated, the supporting documentation shall be reviewed with the individual or his family/caregiver, as appropriate, and such review shall be documented.
[ i. Documentation that the plan for supports has been reviewed by a physician within 30 days of initiation of the service, when any changes are made to the plan for supports, and also reviewed and approved at least annually by a physician.
j. i. ] All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
[ k. j. ] Written documentation of all contacts with the individual's family/caregiver, physicians, providers, and all professionals regarding the individual.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-490. Respite service.
A. Service description.
1. Respite service is temporary, substitute care that is normally provided [ by an unpaid, on a short-term basis for temporary relief of the ] primary caregiver. [ Service shall be provided on a short-term basis for periodic relief of the primary caregiver. Respite service may be provided either through an agency-directed or consumer-directed model. ]
2. Respite service [ may be provided in home and community settings to enable enables ] an individual to maintain the health status and functional skills necessary to live in the community or participate in community activities.
3. [ Respite service may be provided either through an agency-directed or consumer-directed model. Respite service shall be provided:
a. In home and community settings, which may be based in the individual's home; or
b. Under the agency-directed model by enrolled providers licensed to provide center-based respite service, to include a group home or a sponsored residential home.
4. ] Respite service shall be covered in the FIS and CL waivers.
B. Criteria.
1. To qualify for respite service, the individual shall demonstrate (i) a need for assistance with ADLs, community access, self-administration of medications or other medical needs, or monitoring of health status or physical condition and (ii) the family or other unpaid [ caregiver's caregiver has expressed the ] need for relief of caregiving duties.
2. The need for respite service shall be documented in the plan for supports.
3. Allowable activities shall include:
a. Assistance [ support ] with ADLs and IADLs;
b. Support with monitoring [ of ] health status or physical condition;
c. Support with [ prescribed use of ] medication and [ other ] medical needs;
d. [ Support with preparation and eating of meals;
e. Support with housekeeping activities, such as bed-making, cleaning, or the individual's laundry;
f. ] Safety supports;
[ e. g. ] Support [ to participate with participation ] in social, recreational, and community activities;
[ f. h. ] Accompanying the individual to appointments or meetings; and
[ g. i. ] Assistance with bowel/bladder care needs, range of motion activities, routine wound care that does not include sterile technique, and external catheter care when trained and supervised by an RN.
[ 4. Individuals may receive both agency-directed and consumer-directed personal assistance as long as the two service models do not overlap the same days and times.
5. Individuals choosing the consumer-directed option for respite service may receive support from a services facilitator and shall meet requirements for consumer direction as described in 12VAC30-122-150. ]
C. Service units and service limitations.
1. The unit of service shall be one hour. Respite service shall be limited to 480 hours per individual per state fiscal year. If an individual changes waiver programs, this same maximum number of respite hours shall apply. No additional respite hours beyond the 480 hours maximum limit shall be approved for payment. Individuals who are receiving respite service in the FIS or CL waivers through both the agency-directed and consumer-directed models shall not exceed 480 hours per year combined.
2. A person rendering respite service for reimbursement by DMAS shall [ not be the individual's spouse meet the requirements set forth in 12VAC30-122-120 B. ].
3. Any combination of companion service, personal assistance service, and respite service delivered by a single assistant or companion to one individual in the consumer-directed service model shall be limited to 40 hours per week [ for an employer of record (EOR) ]. Assistants who live with the individual, either full time or for substantial amounts of time, shall not be restricted to only 40 hours per week [ for the EOR ]. Individuals may receive more than 40 hours per week, if needed, of respite service from multiple assistants. [ The assistant shall not provide more than 16 hours of consumer-directed services per day. The 16-hour limit shall include hours worked in one day providing a combination of companion, personal assistance, and respite services. ]
4. When specified in the provider's plan for supports, such supportive service may include assistance with IADLs. Respite assistance shall not include skilled nursing service, with the exception of skilled nursing tasks that are delegated pursuant to 18VAC90-19-240 through 18VAC90-19-280, regulated in Chapters 30 (§ 54.1-3000 et seq.) and 34 (§ 54.1-3400 et seq.) of Title 54.1 of the Code of Virginia, as appropriate.
[ 5. Each provider, the individual, the EOR, and the individual's family/caregiver shall have a back-up plan for the individual's care in case the respite assistant does not report for work as expected or terminates employment without prior notice. The support coordinator/case manager shall review the back-up plan and confirm that it will meet the individual's needs.
6. 5. ] Respite service shall not be provided for DMAS reimbursement to relieve staff of group homes, supported living service, or sponsored residential service, as defined by 12VAC35-105-20, or assisted living facilities, as defined by 22VAC40-73-10, where residential supports are provided in shifts. Respite service shall not be provided for DMAS reimbursement by adult foster care providers for an individual residing in that foster home.
[ 7. 6. ] Skill development shall not be provided with respite service.
[ 8. 7. ] The hours to be authorized shall be based on the individual's need. Two individuals in the same home may share supports delivered by one assistant; however, the number of hours billed shall not exceed the number of hours the assistant worked.
[ 9. 8. ] Consumer-directed and agency-directed respite service shall meet the same standards for service limits and authorizations.
D. Provider requirements.
1. Providers shall meet the requirements in 12VAC30-122-110 through 12VAC30-122-140.
2. For [ agency directed ] respite service, the provider shall (i) be licensed by DBHDS as a [ supportive in-home residential service provider, ] center-based respite service provider, [ supportive ] in-home respite service provider, out-of-home respite service provider, or residential respite service provider; (ii) a VDSS-certified foster care home for children or a VDSS-certified adult foster care home for individuals who do not reside in that foster home; (iii) meet the Virginia Department of Health (VDH) licensing requirements; or (iv) have accreditation from a CMS-recognized organization to be a personal care or respite care provider.
3. Providers of [ agency-directed ] respite service shall have a current, signed participation agreement with DMAS. Providers designated on this agreement shall render this service directly and shall bill DMAS directly for Medicaid reimbursement.
4. [ For respite service, the service provider shall complete:
a. An assessment for all individuals prior to admission to services.
b. A plan for supports.
c. Any subsequent reassessments or changes to the plan for supports. All changes that are indicated for an individual's plan for supports shall be reviewed with and agreed to by the individual and, if appropriate, the individual's family/caregiver.
5. Respite assistants shall:
a. Be at least 18 years of age or older;
b. Be able to read and write English to the degree necessary to perform the expected tasks and create and maintain the required documentation;
c. Be physically able to perform the required tasks and have the required skills to perform services as specified in the waiver individual's supporting documentation;
d. Have a valid Social Security Number that has been issued to the respite service provider by the Social Security Administration;
e. Meet the requirements of 12VAC30-122-120 A regarding criminal record checks and, if the waiver individual is a minor, consent to a search of the VDSS Child Protective Services Central Registry.
f. Understand and agree to comply with the DMAS DD Waiver requirements; and
g. Receive tuberculosis screening as specified in the criteria used by the VDH.
h. For consumer directed respite assistants, be willing to attend training at the individual's or family/caregiver's request.
6. Requirements for agency-directed assistants
a. Providers shall ensure that staff providing respite service meet provider training and competency requirements as specified in 12VAC30-122-180.
b. Assistants employed by DBHDS licensed agencies shall meet the requirements as specified in 12VAC35-105-420.
c. Assistants employed by personal care agencies licensed by VDH or having accreditation from a CMS-recognized organization shall have completed an educational curriculum of at least 40 hours of study related to the needs of individuals who have disabilities, including intellectual and developmental disabilities, as ensured by the provider prior to being assigned to support an individual. Assistants shall have the required skills and training to perform the service as specified in the individual's plan for supports and related supporting documentation. An assistant's required training shall be met in one of the following ways:
(1) Registration with the Board of Nursing as a certified nurse aide;
(2) Graduation from an approved educational curriculum as listed by the Board of Nursing; or
(3) Completion of the provider's educational curriculum, as conducted by a licensed RN who shall have at least one year of related clinical nursing experience that may include work in an acute care hospital, public health clinic, home health agency, ICF/IID, or nursing facility.
d. Assistants shall have a satisfactory work record, as evidenced by two references from prior job experiences, if applicable, including no evidence of possible abuse, neglect, or exploitation of elderly persons, children, or adults with disabilities.
e. Persons functioning as assistants shall meet the requirements as specified in 12VAC5-381.
7. Supervision shall be provided to all DSPs and respite assistants.
a. Documentation of supervision shall be completed, signed, and dated by the supervisor and shall include, at a minimum, the following:
(1) Date of contact or observation;
(2) DSP contacted or observed; and
(3) A summary of the contact or observation.
b. When respite service is routine in nature, that is, occurring with a scheduled regularity for specific periods of time and offered in conjunction with personal assistance service, the supervisory visit conducted for personal assistance service may serve as the supervisory visit for the respite service. However, the supervisor shall document supervision of the respite service separately. For this purpose, the same individual record shall be used with a separate section clearly marked for respite service documentation.
c. Based on continuing evaluations of the assistant's performance and individual's needs, the supervisor shall identify any gaps in the assistant's ability to function competently and shall provide training as indicated.
8. ] Supervision requirements for agency-directed respite service.
a. A supervisor shall provide ongoing supervision of all respite assistants. [ b. ] For respite providers that are licensed by DBHDS, a supervisor meeting the requirements of [ 12VAC35-105 12VAC35-105-590 ] shall provide supervision of direct support professional staff.
[ c. b. ] For respite providers who are licensed by VDH or have accreditation from a CMS-recognized organization to be a personal care or respite care provider, the provider shall employ or subcontract with and directly supervise an RN or an LPN, or be an RN or LPN himself, who shall provide ongoing supervision of all assistants. The supervising RN or LPN shall have at least one year of related clinical nursing experience that may include work in an acute care hospital, public health clinic, home health agency, ICF/IID, or nursing facility.
[ 9. For agency directed respite service provided based from the individual's home, in addition to 12VAC30-122-490 D 7: ]
[ d. a. ] The supervisor shall make a home visit to conduct an initial assessment prior to the start of service for all individuals enrolled in a DD Waiver who have been approved to receive respite service. [ The supervisor shall also perform any subsequent reassessments or changes to the plan for supports. All changes that are indicated for an individual's plan for supports shall be reviewed with and agreed to by the individual and, if appropriate, the individual's family/caregiver.
e. The supervisor shall make supervisory home visits or center-based visits to DBHDS-licensed settings as often as needed to ensure both quality and appropriateness of the service. When respite service is received on a routine basis, the minimum frequency of these supervisory visits shall be at least every 90 days under the agency-directed model, depending on the individual's needs. Documentation of supervision shall be completed, signed, and dated by the supervisor and shall include, at a minimum, the following:
(1) Date of contact or observation;
(2) Person contacted or observed; and
(3) A summary of the contact or observation.
f. When respite service is not received on a routine basis but is episodic in nature, the supervisor shall conduct the initial home visit with the respite assistant immediately preceding the start of service and make a second home visit within the respite service period. The supervisor or services facilitator, as appropriate, shall review the use of the respite service either every six months or upon the use of 240 respite service hours, whichever comes first.
g. When respite service is routine in nature, that is, occurring with a scheduled regularity for specific periods of time and offered in conjunction with personal assistance service, the supervisory visit conducted for personal assistance service may serve as the supervisory visit for the respite service. However, the supervisor or service facilitator, as appropriate, shall document supervision of the respite service separately. For this purpose, the same individual record shall be used with a separate section clearly marked for respite service documentation.
h. Based on continuing evaluations of the assistant's performance and individual's needs, the supervisor shall identify any gaps in the assistant's ability to function competently and shall provide training as indicated.
b. If the individual is also attempting to access an assessment for personal assistance services, one assessment may be conducted for both services at the same time. However, the supervisor shall document supervision of the respite service separately. For this purpose, the same individual record shall be used with a separate section clearly marked for respite service documentation.
c. When the service is delivered on a routine basis, the minimum frequency of required supervisory visits shall be every 90 days.
d. When respite service is not received on a routine basis but is episodic in nature, the supervisor shall conduct the initial home visit with the DSP/respite assistant immediately preceding the start of service and make a second home visit within the respite service period. The supervisor or services facilitator, as appropriate, shall review the use of the respite service either every six months or upon the use of 240 respite service hours, whichever comes first.
10. For center-based respite service, in addition to 12VAC30-122-490 D 7, the supervisor shall provide ongoing supervision to all DSPs/respite assistants in DBHDS-licensed settings no less than quarterly to ensure both quality and appropriateness of the service ].
[ 5. 11. ] Service facilitation requirements for respite service shall be the same as those set forth in 12VAC30-122-150.
[ 6. Requirements for agency-directed assistants.
a. Providers shall ensure that staff providing respite service meet provider competency training requirements as specified in 12VAC30-122-180.
b. Assistants employed by personal assistance agencies licensed by VDH or having accreditation from a CMS-recognized organization shall have completed an educational curriculum of at least 40 hours of study related to the needs of individuals who have disabilities, including intellectual and developmental disabilities, as ensured by the provider prior to being assigned to support an individual. Assistants shall have the required skills and training to perform the service as specified in the individual's plan for supports and related supporting documentation. An assistant's required training shall be met in one of the following ways:
(1) Registration with the Board of Nursing as a certified nurse aide;
(2) Graduation from an approved educational curriculum as listed by the Board of Nursing; or
(3) Completion of the provider's educational curriculum, as conducted by a licensed RN who shall have at least one year of related clinical nursing experience that may include work in an acute care hospital, public health clinic, home health agency, ICF/IID, or nursing facility.
c. Assistants shall have a satisfactory work record, as evidenced by two references from prior job experiences, if applicable, including no evidence of possible abuse, neglect, or exploitation of elderly persons, children, or adults with disabilities.
d. When assistants are absent or otherwise unable to render scheduled supports to individuals enrolled in the waiver, the provider shall be responsible for ensuring that the service continues to be provided to the affected individuals.
(1) The provider may either provide another assistant, obtain a substitute assistant from another provider if the lapse in coverage is to be less than two weeks in duration, or transfer the individual to another respite provider. The provider who holds the service authorization to provide service to the individual enrolled in the waiver shall contact the support coordinator/case manager to determine if additional or modified service authorization is necessary.
(2) If no other provider is available who can supply a substitute assistant, the provider shall notify the individual and the individual's family/caregiver, as appropriate, and the support coordinator/case manager so that the support coordinator/case manager may find another available provider of the individual's choice.
e. During temporary, short-term lapses in coverage that are not expected to exceed approximately two weeks in duration, the following procedures shall apply:
(1) The service authorized provider shall supervise the substitute assistant;
(2) The provider of the substitute assistant shall send a copy of the assistant's daily documentation signed by the assistant, the individual, and the individual's family/caregiver, as appropriate, to the provider having the service authorization; and
(3) The service authorized provider shall bill DMAS for service rendered by the substitute assistant.
f. If a provider secures a substitute assistant, the provider agency shall be responsible for ensuring that all DMAS requirements continue to be met, including documentation of service rendered by the substitute assistant and documentation that the substitute assistant's qualifications meet DMAS requirements. The two providers involved shall be responsible for negotiating the financial arrangements of paying the substitute assistant
12. For agency directed respite based in an individual's home, when assistants are absent or otherwise unable to render scheduled supports to individuals enrolled in the waiver, the provider shall be responsible for ensuring that the service continues to be provided to the affected individuals.
13. All individuals shall have a backup plan prior to initiating services in cases of emergency or should the provider be unable to render services as needed. This backup plan shall be documented and shared with the provider, services facilitator, and support coordinator at the onset of services and updated with the provider and support coordinator as necessary ].
E. Service documentation and requirements [ for agency-directed service and consumer-directed service ].
1. Agency-directed providers [ or the services facilitator, or the EOR in the absence of a services facilitator, ] shall maintain records regarding each individual who is receiving respite service.
2. At a minimum, the records shall contain:
a. A copy of the most recently completed age-appropriate assessment and, as needed, an initial assessment completed by the supervisor or services facilitator prior to or on the date service is initiated.
b. [ The provider's most recently updated plan for supports detailed in 12VAC30-122-120. The provider and service facilitator's plan for supports per requirements detailed in 12VAC30-122-120. ]
c. [ Documentation indicating that the plan for supports desired outcomes and support activities have been reviewed by the provider quarterly, annually, and more often as needed. At a minimum, monthly verification by the supervisor of the service and hours rendered and billed to DMAS. The results of the review shall be submitted to the support coordinator. A written review supported by documentation in the individual's record that is submitted to the support coordinator at least quarterly if services are delivered that quarter with the plan for supports if modified. ] For the annual review and in cases where the plan for supports is modified, the plan for supports shall be reviewed with and agreed to by the individual enrolled in the waiver and the individual's family/caregiver, as appropriate;
d. Supervisor's [ or services facilitator's ] summarizing notes recorded and dated during any contacts with the assistant [ and during supervisory visits to the individual's home ];
e. Documentation by the service supervisor [ or consumer-directed services facilitator ] in a summary note following significant contacts with the assistant and home visits with the individual the following:
(1) Whether the service continues to be appropriate;
(2) Whether the plan for supports is adequate to meet the individual's needs or changes are needed in the plan;
[ (3) The individual's satisfaction with the service;
(4) (3) ] The presence or absence of the assistant during the supervisor's visit [ if not a center-based service ];
[ (5) (4) ] Any suspected abuse, neglect, or exploitation and to whom it was reported; and
[ (6) (5) ] Any hospitalization or change in medical condition, functioning, or cognitive status;
f. All correspondence to the individual and the individual's family/caregiver, as appropriate, the [ support coordinator/case manager support coordinator ], DMAS, and DBHDS;
g. Contacts made with the individual's family/caregiver, physicians, providers, and all professionals concerning the individual; and
h. The specific service delivered to the individual enrolled in the waiver by the assistant dated the day of service delivery and the individual's unique, specific responses as well as:
[ (1) The respite assistant's arrival and departure times;
(2) The respite assistant's weekly comments or observations about the individual enrolled in the waiver to include individual-specific observations of the individual's physical and emotional condition, daily activities, and responses to the service rendered; and
(3) The respite assistant's, individual's, and the individual's family/caregiver's, as appropriate, weekly signatures recorded on the last day of service delivery for any given week to verify that respite service during that week have been rendered.
3. (1) For home-based respite service, the respite assistant's arrival and departure times, in addition to the weekly signatures of the respite assistant, individual, and the individual's family member/caregiver, as appropriate, recorded on the last day of service delivery for any given week to verify that respite service during that week have been rendered.
(2) For center-based respite service, the individual's arrival and departure times from the center, group home, or sponsored residential site and documentation specific to 12VAC30-122-120 A 10 d. ]
(3) ] Respite service records shall be separated from those of other nonwaiver services, such as home health service.
[ 4. (4) ] Progress notes shall meet the standards contained in 12VAC30-122-120 A.
[ 5. (5) Consumer-directed documentation requirements are set forth in 12VAC30-122-500 E.
(6) ] Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-500. [ Service Services ] facilitation service. .
A. Service description. Individuals enrolled in the [ waiver FIS or CL waivers ] may select the consumer-directed model of service delivery for certain services, absent any of the specified conditions that preclude such a choice, and may also receive support from a services facilitator. Services facilitation service shall be a separate waiver service and shall be used only in conjunction with consumer-directed personal assistance service, respite service, or companion service.
B. Criteria and allowable activities.
1. [ Service Services ] facilitators shall train individuals enrolled in the waiver, or the individual's employer of record (EOR), as appropriate, to direct, such as select, hire, train, supervise, and authorize timesheets of their own assistants who are rendering personal assistance services, respite services, and companion services.
2. The [ service services ] facilitator shall also make an initial comprehensive home visit to collaborate with the individual and the individual's family/caregiver, as appropriate, (i) to identify the individual's needs for a requested consumer-directed service; (ii) to assist in the development of the plan for supports with the individual and the individual's family/caregiver, as appropriate; (iii) provide employer management training to the individual or EOR, as appropriate, on his responsibilities as an employer; and (iv) to provide ongoing support of the consumer-directed model of service. The [ service services ] facilitator shall provide employer management training to the [ individual or ] EOR [ , as appropriate, ] within seven days of the initial visit.
a. The initial comprehensive home visit shall be completed only once upon the individual's entry into the consumer-directed model of service regardless of the number or type of consumer-directed services that an individual is approved to receive.
b. If an individual changes [ service services ] facilitators, the new services facilitator shall complete a reassessment visit in lieu of a comprehensive visit.
c. The employer management training shall be completed before the individual or EOR may hire an assistant who is to be reimbursed by DMAS.
d. After the initial visit, the [ service services ] facilitator shall continue to monitor the individual's plan for supports quarterly (i.e., every 90 days) and more often as needed. If consumer-directed respite service is provided, the services facilitator shall review the utilization of consumer-directed respite service either every six months or upon the use of 240 respite service hours, whichever comes first.
3. [ A face-to-face An in-person ] meeting shall occur between the [ service services ] facilitator and the individual at least every six months to reassess the individual's needs and to ensure appropriateness of any consumer-directed service received by the individual. During these visits with the individual, the [ service services ] facilitator shall observe, evaluate, and consult with the individual, EOR, and the individual's family/caregiver, as appropriate, for the purpose of assessing the adequacy and appropriateness of consumer-directed service with regard to the individual's current functioning, medical needs, and social needs. The services facilitator's written summary of the visit shall include:
a. Discussion with the individual and EOR or individual's family/caregiver, as appropriate, whether the particular consumer-directed service is adequate to meet the individual's needs;
b. Any suspected abuse, neglect, or exploitation and to whom it was reported;
c. Any special tasks performed by the assistant or companion and the assistant's or companion's qualifications to perform these tasks;
d. The individual's and EOR's or individual's family/caregiver's, as appropriate, satisfaction with the assistant's or companion's service;
e. Any hospitalization or change in medical condition, functioning, or cognitive status;
f. The presence or absence of the assistant or companion in the home during the [ service services ] facilitator's visit; and
g. Any other service received and the amount.
4. The [ service services ] facilitator, during routine quarterly visits, shall also review and verify [ timesheets time worked ] as needed to ensure that the number of hours approved in the plan for supports is not exceeded. If discrepancies are identified, the [ service services ] facilitator shall discuss these with the individual or EOR to resolve discrepancies and shall notify the fiscal/employer agent as defined in 12VAC30-122-170. If an individual is consistently identified as having discrepancies in his timesheets, the [ service services ] facilitator shall contact the support coordinator. Failure to review and verify timesheets and maintain documentation of such reviews shall subject the provider to recovery of payments made by DMAS in accordance with 12VAC30-80-130.
5. The [ service services ] facilitator shall be available during standard business hours to the individual or EOR by telephone.
6. The consumer-directed [ service services ] facilitator shall assist the individual or EOR with employer issues as requested by either the individual or EOR.
7. The [ service services ] facilitator shall also complete the assessments, reassessments, and supporting documentation necessary for consumer-directed service.
8. Service facilitation service shall be provided on an as-needed basis as mutually agreed to by the individual, EOR, and [ service services ] facilitator but at a minimum quarterly routine visits [ shall take place ]. [ Service Services ] facilitator service shall be documented in the supporting documentation for consumer-directed service, and the service facilitation provider shall bill consistent with the supporting documentation. Claims that are not adequately supported by this supporting documentation may be subject to a DMAS recovery of expenditures.
9. If an EOR is consistently unable to hire and retain an assistant to provide consumer-directed services, the [ service services ] facilitator shall contact the support coordinator and DBHDS to transfer the individual, at the choice of the individual, to a provider that provides Medicaid-funded agency-directed companion service, personal assistance service, or respite care service, as may be appropriate.
10. If an individual enrolled in consumer-directed service has a lapse in consumer-directed service for more than 60 consecutive calendar days, the [ service services ] facilitator, or the individual or family/caregiver functioning as the [ service services ] facilitator, shall notify the support coordinator so that consumer-directed service may be discontinued, and the option afforded to the individual to change to agency-directed service as long as the individual still qualifies for the service.
C. Service units and limits. The limits and requirements for individuals' selection of consumer-directed service shall be as follows:
1. In order to be approved to use the consumer-directed model of service, the individual enrolled in the waiver shall meet the requirements as specified in 12VAC30-122-150. Support coordinators shall document in the individual support plan the individual's choice for the consumer-directed model and whether or not the individual chooses service facilitation. The support coordinator shall document in the individual's record that the individual [ can will ] serve as the EOR or [ if that ] there is a need [ or desire ] for another person to serve as the EOR on behalf of the individual.
2. The consumer-directed [ service services ] facilitator who is to be reimbursed by DMAS shall not be the individual enrolled in the waiver; a direct service provider; the individual's spouse; a parent or legal guardian of the individual who is a minor child; or the EOR who is employing the assistant or companion.
3. The services facilitator shall document the individual's back-up plan in case the assistant or companion does not report for work as expected or terminates employment without prior notice.
4. Should the assistant or companion not report for work or terminate his employment without notice, then the [ service services ] facilitator shall, upon the individual's or EOR's request, provide management training to ensure that the individual or the EOR is able to recruit and employ a new assistant or companion.
D. Provider requirements.
1. To be enrolled as a [ service services ] facilitator and maintain provider status, the services facilitator provider shall have sufficient resources to perform the required activities, including the ability to maintain and retain business and professional records sufficient to document fully and accurately the nature, scope, and details of the service provided.
2. All consumer-directed [ service services ] facilitators, whether employed by or contracted with a DMAS enrolled [ service services ] facilitator provider, shall meet all of the qualifications set out in this subsection. To be enrolled, the [ service services ] facilitator shall also meet the combination of work experience and relevant education set out in this subsection that indicate the possession of the specific knowledge, skills, and abilities to perform this function.
a. If the [ service services ] facilitator is not an RN then, within 30 days from the start of such service, the [ service services ] facilitator shall inform the primary health care provider for the individual enrolled in the waiver that consumer-directed service is being provided and request skilled nursing or other consultation as needed by the individual. Prior to contacting the primary health care provider, the [ service services ] facilitator shall obtain the individual's written consent to make such contact. This written consent shall be retained by the [ service services ] facilitator in the individual's record.
b. All [ service services ] facilitators shall possess, at a minimum, either (i) an associate's degree from an accredited college in a health or human services field or be a registered nurse currently licensed to practice in the Commonwealth or hold a multistate licensure privilege, and demonstrate at least two years of satisfactory direct care experience supporting individuals with disabilities or older adults or children or (ii) have a bachelor's degree in a non-health or human services field and a minimum of three years of satisfactory direct care experience supporting individuals with disabilities or older adults. [ Service Services ] facilitators enrolled prior to January 11, 2016, are not required to meet the education requirements.
c. All consumer-directed [ service services ] facilitators shall:
(1) Have a satisfactory work record as evidenced by two references from prior job experiences from any human services work. Such references shall not include any evidence of abuse, neglect, or exploitation of elderly individuals, persons with disabilities, or children;
(2) Submit to a criminal background check [ within 15 days of prior to ] employment. Proof that the criminal record check was conducted shall be maintained in the record of the [ service services ] facilitator;
(3) If providing service to minors, submit to a search of the VDSS Child Protective Services Central Registry; and
(4) Not be debarred, suspended, or otherwise excluded from participating in federal health care programs, as listed on the federal List of Excluded Individuals and Entities (LEIE) database at http://www.olg.hhs.govfraud/exclusions/exclusions list.asp.
d. The services facilitator shall not be compensated for service provided to the waiver individual [ after the initial prior to the results of the background check ] or any subsequent background check verifies that the [ service services ] facilitator (i) has been convicted of a barrier crime as defined in 12VAC30-122-20; (ii) has a founded complaint confirmed by the VDSS Child Protective Services Central Registry; or (iii) is found to be listed on the LEIE database. In accordance with 12VAC30-80-130, DMAS shall seek refunds of overpayments.
e. All [ service services ] facilitators shall complete the DMAS-approved services facilitator training and pass the corresponding competency assessment with a score of at least 80% prior to being approved as a [ service services ] facilitator or being reimbursed for waiver services. The competency assessment and all corresponding competency assessments shall be kept in the [ service services ] facilitator's personnel record.
f. Failure to complete the competency assessment prior to providing this service shall result in a retraction of Medicaid payment or the termination of the provider agreement, or both.
g. As a component of the renewal of the provider agreement, all consumer-directed [ service services ] facilitators shall take and pass the competency assessment every five years and achieve a score of at least 80%.
h. The consumer-directed [ service services ] facilitator shall have access to a computer with secure Internet access that meets the requirements of 45 CFR Part 164 for the electronic exchange of information. Electronic exchange of information shall include, for example, checking individual eligibility, submission of service authorizations, submission of information to the fiscal employer agent, and billing for service.
i. All consumer-directed [ service services ] facilitators shall possess a demonstrable combination of work experience and relevant education that indicates possession of the following knowledge, skills, and abilities. Such knowledge, skills, and abilities shall be documented on the application form, found in supporting documentation, or be observed during the job interview. Observations during the interview shall be documented. The knowledge, skills, and abilities include:
(1) Knowledge of:
(a) Types of functional limitations and health problems that may occur in individuals with developmental disabilities, as well as strategies to reduce limitations and health problems;
(b) Physical assistance that may be required by individuals with developmental disabilities, such as transferring, bathing techniques, bowel and bladder care, and the approximate time those activities normally take;
(c) Equipment and environmental modifications that may be required by individuals with developmental disabilities that reduce the need for human help and improve safety;
(d) Various long-term care program requirements, including nursing home and ICF/IID placement criteria; Medicaid waiver services; and other federal, state, and local resources that provide personal assistance service, respite service, and companion service;
(e) DD Waivers requirements, as well as the administrative duties for which the [ service services ] facilitator will be responsible;
(f) Conducting assessments, including environmental, psychosocial, health, and functional factors, and their uses in service planning;
(g) Interviewing techniques;
(h) The individual's right to make decisions about, direct the provisions of, and control his consumer-directed personal assistance service, companion service, and respite service, including hiring, training, managing, approving timesheets, and firing an assistant or companion;
(i) The principles of human behavior and interpersonal relationships; and
(j) General principles of record documentation.
(2) Skills in:
(a) Negotiating with individuals and the individual's family/caregivers, as appropriate, and providers;
(b) Assessing, supporting, observing, recording, and reporting behaviors;
(c) Identifying, developing, or providing service to individuals with developmental disabilities; and
(d) Identifying services within the established system to meet the individual's needs.
(3) Abilities to:
(a) Report findings of the assessment or onsite visit, either in writing or an alternative format, for individuals who have visual impairments;
(b) Demonstrate a positive regard for individuals and their families;
(c) Be persistent and remain objective;
(d) Work independently, performing position duties under general supervision;
(e) Communicate effectively, orally and in writing; and
(f) Develop a rapport and communicate with individuals of diverse cultural backgrounds.
E. Service documentation and requirements.
1. In addition to the documentation required by 12VAC30-122-340, 12VAC30-122-460, and 12VAC30-122-490, the services facilitator shall maintain a record of each individual containing elements as set out in this section. The [ service services ] facilitator's record about the individual shall contain:
a. Documentation of all employer management training provided to the individual enrolled in the waiver and the EOR, as appropriate, including the individual's or the EOR's, as appropriate, receipt of training on his responsibility for the accuracy and timeliness of the assistant's or companion's timesheets;
b. All documents signed by the individual enrolled in the waiver or the EOR, as appropriate, that acknowledge their legal responsibilities as the employer; and
c. All contacts and consultations documented in the individual's medical record. Failure to document such contacts and consultations shall be subject to a DMAS recovery of payments made.
2. [ Provider documentation of service rendered that merely constitutes notes that are copied from previous dates of service and redated or that are prepackaged shall not constitute satisfactory progress notes. ] Progress notes shall meet the standards contained in 12VAC30-122-120.
3. CD [ service services ] facilitators responsible for individual assessment and reassessment shall maintain the following listed records and documentation in individuals' records:
a. All copies of the consumer-directed plan for support, all supporting documentation related to consumer-directed services, and DMAS-225 (Medicaid Tong-Term Care Communication Form), which is the form used by the support coordinator to report information about patient pay amount changes in an individual's situation.
b. A copy of the most recently completed SIS® assessment or the approved alternative assessment form noted in 12VAC30-122-200 A, and an initial assessment completed by the [ service services ] facilitator prior to or on the date the service is initiated.
c. Consumer-directed [ service services ] facilitator's notes recorded and dated at the time of service delivery. The consumer-directed services facilitator's written summary of visits shall include at minimum:
(1) Discussion with the individual and EOR or individual's family/caregiver, as appropriate, whether the particular consumer-directed service is adequate to meet the individual's needs;
(2) Any suspected abuse, neglect, or exploitation and to whom it was reported;
(3) Any special tasks performed by the assistant and the assistant's qualifications to perform these tasks;
(4) The individual's and EOR's or individual's family/caregiver's, as appropriate, satisfaction with the assistant's service;
(5) Any hospitalization or change in medical condition, functioning, or cognitive status; and
(6) The presence or absence of the assistant in the home during the services facilitator's visit.
d. All correspondence to the individual and EOR, as appropriate, to others concerning the individual, and to the support coordinator, DMAS, and DBHDS.
e. All management training provided to the individual or EOR, as appropriate, including the responsibility for the accuracy of the timesheets.
f. All documents signed by the individual or EOR, as appropriate, that acknowledge the responsibilities of the employer.
g. Documentation indicating that desired outcomes and support activities of the plan for supports have been reviewed by the consumer-directed [ service services ] facilitator provider quarterly, annually, and more often as needed. The results of the review shall be submitted to the support coordinator. For the annual review and in cases where the plan for supports is modified, the plan for supports shall be reviewed with and agreed to by the individual enrolled in the waiver and the individual's family/caregiver, as appropriate, and signed and dated by the individual or the individual's family/caregiver
h. Contacts made with the individual's family/caregiver, physicians, providers, and all professionals concerning the individual.
4. Service facilitation records shall be provided to DMAS or DBHDS upon request.
5. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-510. Shared living [ support ] service.
A. Service description. Shared living [ support ] service means Medicaid coverage of a portion of the total cost of rent, food, and utilities that can be reasonably attributed to a live-in roommate who has no legal responsibility to financially support the individual who is enrolled in the waiver. The types of assistance provided are expected to vary from individual to individual and shall be set out in a detailed, signed, and dated agreement between the individual and roommate. This service shall require the use of a shared living [ support ] service administrative provider enrolled with DMAS that shall be responsible for directly coordinating the service and directly billing DMAS for reimbursement. Shared living [ support ] service shall be covered in the FIS, CL, and BI waivers.
B. Criteria and allowable activities.
1. The individual, who shall be at least 18 years of age, shall select his roommate, who shall also be at least 18 years of age, and, together through a [ person-centered ] planning process, they shall determine the assistance to be provided by the roommate based on the individual's needs and preferences. The individual shall reside in his own home or in a residence leased by the individual.
2. Reimbursable room and board for the roommate shall be established through the service authorization process per the CMS-approved rate methodology.
3. The individual shall be receiving at least one other waiver service in order to receive Medicaid coverage of shared living [ support ] service.
4. Allowable activities shall include:
a. Fellowship [ , which means a close association or communion with friends or equals with whom an individual has shared interests, experiences, and purpose ];
b. Safety supports;
c. Limited help with ADLs and IADLs that shall account for no more than 20% of the anticipated roommate time and may include:
(1) Meal preparation;
(2) Light housework;
(3) Medications reminders; and
(4) Routine prompting or intermittent direct assistance with ADLs.
C. Service units and limits. The unit of service shall be a month or may be a partial month for months in which the service begins or ends.
1. The roommate shall complete and pass background checks, including criminal registry checks required by §§ 37.2-416, 37.2-506, and 37.2-607 of the Code of Virginia.
2. The roommate shall successfully meet the training requirements set out in the written [ supports ] agreement including CPR training, safety awareness, fire safety and disaster planning, and conflict management and resolution.
3. Shared living [ support ] service shall not be covered for individuals who are simultaneously receiving group home residential service, sponsored residential service, or supported living residential service.
4. The roommate shall not have the responsibility for providing skill-building or medical services.
5. The roommate shall not be the spouse, parent, [ grandparent, ] or guardian of the individual.
[ 6. If the individual is without a roommate for more than 60 calendar days, the administrating agency must submit a termination for services pending the replacement of the roommate. ]
D. Provider requirements.
1. Providers shall meet the service coverage requirements in this section and the general conditions and requirements for home and community-based participating providers as specified in 12VAC30-122-110 through 12VAC30-122-140.
2. Shared living [ support ] service administrative providers shall be licensed by DBHDS to provide service to individuals with developmental disabilities and shall manage the administrative aspects of this service, including roommate matching as needed, background checks, training, periodic onsite monitoring, and disbursing funds to the individual.
3. Shared living [ support ] service administrative providers shall have a current, signed participation agreement with DMAS in order to provide this service. The provider designated in this agreement shall coordinate the shared living [ support ] service and submit claims directly to DMAS for reimbursement. This shared living [ support ] service administrative provider shall be reimbursed a flat fee payment for the completion of these duties. DMAS may audit such provider's records for compliance with the requirements in this section.
4. Reimbursement for shared living [ support ] service shall be based upon compliance with DMAS submission requirements for claims and supporting [ progress notes ] documentation as may be required as proof of service delivery. Claims that are not supported by the required [ progress ] notes documentation shall be subject to recovery by DMAS of any expenditures that may have been made.
5. [ The administrative provider shall ensure that there is a back-up plan in place in the event that the roommate is unable or unavailable to provide the agreed-to supports. All individuals shall have a backup plan prior to initiating services in cases of emergency or should the roommate be unable to render services as needed. This backup plan shall be shared with the administrative provider and support coordinator at the onset of services and updated with the administrative provider and support coordinator as necessary. ]
6. The administrative provider shall submit monthly claims for shared living [ support ] service for reimbursement based upon the amount determined through the service authorization process.
E. Service documentation and requirements.
1. The administrative provider shall maintain documentation of the actual rent and submit the documentation with the service authorization request for shared living [ support ] service.
2. For quality management review and utilization review purposes, the administrative provider shall be required to maintain and present to DMAS, as requested, an agreement that identifies what supports the roommate will provide, and this [ supports ] agreement shall be signed by the individual and the roommate. The individual's support coordinator shall retain a copy of this signed, executed agreement in the particular individual's file.
3. [ The administrative provider shall maintain documentation of the roommate's participation in all required training.
4. ] The administrative provider shall submit monthly claims for shared living [ support ] service reimbursement based upon the amount determined through the service authorization process.
[ 4. 5. ] The administrative provider shall maintain weekly summaries of supports provided by the roommate and signed by the roommate.
[ 5. 6. ] Documentation of the [ administrative provider's ] 90-day face-to-face contact with the individual that includes the status of the individual [ , satisfaction with the service, ] and resolution of any issues related to service provision. This 90-day face-to-face shall take place in the individual's home. [ A progress note documenting Documentation of ] the [ face-to-face in-person ] contact and observations shall be provided to the support coordinator quarterly.
[ 6. 7. ] Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-520. Skilled nursing service.
A. Services description. Skilled nursing service shall provide [ part-time or ] intermittent care [ , up to, but not to exceed 21 hours per week, ] that may be provided concurrently with other services due to the medical nature of the supports provided [ , excluding private duty nursing services ]. Skilled nursing service shall be provided for individuals enrolled in the waiver having serious medical conditions and complex health care needs who have exhausted their home health benefits and who require specific skilled nursing services [ that cannot be provided by non-nursing personnel ]. Skilled nursing service shall be covered in the FIS and CL waivers.
B. Criteria and allowable activities. The individuals who are authorized to receive this service shall require specific skilled nursing service as documented in the plan for supports [ and ordered by a physician ]. This service shall be rendered to the individual in his residence or other community settings on a regularly scheduled or intermittent basis in accordance with the plan for supports. Allowable activities shall be ordered and certified as medically necessary by a Virginia-licensed physician. The ordered services may include:
1. [ Consultation, assistance to direct support staff, and nurse delegation; Administering medications and other medical treatment; ]
2. [ Training Skilled training ] of family and other caregivers;
3. Monitoring an individual's medical status;
4. [ Administering medications and other medical treatment Consultation, guidance, and delegation of skilled tasks to direct support staff in accordance with 18VAC90-19-280 ]; or
5. Assurance that all items listed in subdivisions B 1 through B 4 of this section are carried out in accordance with the plan for supports.
C. Service units and limits.
1. Skilled nursing service shall be ordered by a physician and shall be medically necessary. [ The medical necessity for skilled nursing services shall be documented in the individual's ISP. Once the medical necessity can no longer be demonstrated, this service shall be terminated. ]
2. Skilled nursing service shall not be available unless an individual has exhausted all available home health benefits.
3. This service shall be rendered and billed in quarter-hour increments. [ Individuals receiving this service shall not be required to meet the criteria for the receipt of home health services. Skilled nursing service shall not be limited by the acute, time-limited standards for home health services as contained in the State Plan for Medical Assistance. ]
4. Individuals enrolled in the waiver shall not be authorized to receive waiver skilled nursing service when private duty nursing service is authorized [ or concurrently (i.e., the same dates and times) with personal assistance service. For an individual younger than 21 years of age, waiver skilled nursing services shall not be authorized or covered if the necessary service is available under EPSDT. The support coordinator shall assist such a child with obtaining the medically necessary service through the EPSDT benefit except in cases that require nurse delegation ].
[ 5. Foster care providers shall not be the skilled nursing service providers for the same individuals for whom they provide foster care.
6. The support coordinator shall assist an individual who has short-term, acute, and limited-in-nature skilled nursing needs in accessing the home health service benefit under the State Plan for Medical Assistance.
7. The support coordinator shall assist an individual who has skilled nursing needs that are expected to be longer term, but intermittent in nature, with accessing waiver skilled nursing service. ]
D. Provider requirements.
1. Providers shall either employ or subcontract with nurses who are currently licensed as either RNs or LPNs under Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia or who hold a current multistate licensure privilege to practice nursing in the Commonwealth.
2. Skilled nursing service may be provided by either (i) a licensed RN or LPN, who is under the supervision of a licensed RN, employed by a DMAS-enrolled home health provider or (ii) a licensed RN or LPN, who is under the supervision of a licensed RN, contracted with or employed by a DBHDS-licensed day support, respite, or residential services provider.
3. Providers shall maintain documentation of required licenses in the appropriate employee personnel records. Such documentation shall be provided to either DMAS or DBHDS upon request.
[ 4. Foster care providers shall not act as skilled nursing service providers for individuals for whom they provide foster care. ]
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. A copy of the completed age-appropriate assessment as detailed in 12VAC30-122-200;
b. A plan for supports as detailed in 12VAC30-122-120 and the CMS-485;
c. [ Progress note documentation Documentation ] of all training, including the dates and times, provided to family/caregivers or staff, or both, including the person being trained and the content of the training. Training of professional staff shall be consistent with the Regulations Governing the Practice of Nursing (18VAC90-19);
d. Documentation of the physician's determination of medical necessity prior to services being rendered;
e. [ Progress note documentation indicating Documentation summarizing interventions, results of treatment,] the dates and times of nursing interventions that are provided, and the amount and type of service;
f. A written review supported by documentation in the individuals' record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified;
[ g. Documentation that the plan for supports has been reviewed by a physician within 30 days of initiation of services, when any changes are made to the plan for supports, and also reviewed and approved at least annually by a physician;
h. g. ] All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS; and
[ i. h. ] Written documentation of all contacts with the individual's family/caregiver, physicians, providers, and all professionals regarding the individual [ as well as written confirmation from the individual or family that they received services unless services are delivered in a group home ].
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-530. Sponsored residential service.
A. Service description. Sponsored residential service means a residential service that consists of skill-building, routine supports, general supports, and safety supports that are provided in the homes of families or persons (sponsors) providing supports under the supervision of a DBHDS-licensed provider that enable an individual to acquire, retain, or improve the self-help, socialization, and adaptive skills necessary to reside successfully in home and community settings. This service shall include skills development with the provision of supports, as needed. Sponsored residential service shall be covered in the CL waiver.
B. Criteria and allowable activities.
1. This service shall only be authorized for Medicaid reimbursement when through the person-centered planning process this service is determined necessary to meet the individual's needs. This service may be provided individually or simultaneously to up to two individuals living in the same home, depending on the required support.
2. Allowable activities shall include:
a. Skill-building and routine supports related to ADLs and IADLs;
b. Skill-building and routine and safety supports related to the use of community resources, such as transportation, shopping, restaurant dining, and participating in social and recreational activities. The cost of participation in the actual social or recreational activity shall not be reimbursed;
c. Supporting the individual in replacing challenging behaviors with positive, accepted behaviors for home and community environments;
d. Monitoring and supporting the individual's health and physical condition and providing supports with medication management and other medical needs;
e. Providing routine supports and safety supports with transportation to and from community locations and resources;
f. Providing general supports, as needed; and
g. Providing safety supports to ensure the individual's health and safety.
C. Service units and limits.
1. The unit of service shall be one day and billing shall not exceed 344 days per ISP year, as indicated in the plan for supports of the individuals who are authorized to receive this service.
2. This service shall be provided on an individual-specific basis according to the ISP and service setting requirements.
3. Sponsored residential service shall be a tiered service for reimbursement purposes and providers shall only be reimbursed for the individual's assigned level and tier.
4. DMAS coverage of this service shall be limited to no more than two individuals per residential setting. Providers shall not bill for service rendered to more than two individuals living in the same residential setting.
5. This service shall be provided to individuals up to 24 hours per day by the sponsor family or qualified staff.
6. Room and board shall not be components of this service.
7. This service shall not be simultaneously covered for individuals who are receiving personal assistance or other residential service under the waiver, such as shared living service, supported living service, in-home support service, or group home residential service that provide comparable supports, as determined by DMAS.
D. Provider requirements.
1. Providers shall meet all of the requirements set forth in 12VAC30-122-110 through 12VAC30-122-140.
2. Sponsored residential service shall be provided by agencies licensed by DBHDS as a provider of sponsored residential service.
3. Providers of this service shall have a current, signed participation agreement with DMAS. Providers as designated on this agreement shall render this service directly and shall bill DMAS directly for Medicaid reimbursement.
4. Providers shall ensure that sponsors providing [ sponsored residential ] service meet provider [ competency ] training [ and competency ] requirements as specified in 12VAC30-122-180.
5. [ A supervisor meeting the requirements of 12VAC35-105 shall provide supervision of the sponsor. Documentation of supervision shall be completed, signed by the sponsor designated to perform the supervision and oversight, and include the following: Supervision of direct support staff shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight. ]
[ a. Date of contact or observation;
b. Person contacted or observed;
c. A summary about the sponsor's performance and service delivery;
d. Any action planned or taken to correct problems identified during supervision and oversight; and
e. On a semiannual basis, observations documented by the supervisor concerning the individual's satisfaction with service provision. ]
6. Sponsored residential settings shall comply with the HCBS setting requirements per 42 CFR 441.301. [ In these settings, lease or residency agreements shall comply with and support individual choice of service and setting. ]
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. A copy of the most current, completed, standard, age-appropriate assessment form as detailed in 12VAC30-122-200.
b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
c. [ Progress note documentation confirming the amount of the individual's time in service and providing specific information regarding the individual's responses to various settings and supports. Observations of the individual's responses to service shall be available in at least a daily note. Documentation as detailed in 12VAC30-122-120. ] Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, then clearly documented in the progress notes or [ supports ] checklist.
d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.
e. A written review supported by documentation in the individuals' record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified. [ For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented. ]
f. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
g. Written documentation of contacts made with the individual's family/caregiver, physicians, providers, and all professionals concerning the individual.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-540. Supported living residential service.
A. Service description. Supported living residential service shall take place in [ an apartment a residential ] setting operated by a DBHDS-licensed provider of supervised living residential service or supportive in-home service [ . This service shall consist and consists ] of skill-building, routine and general supports, and safety supports that enable an individual to acquire, retain, or improve the self-help, socialization, and adaptive skills necessary to reside successfully in home and community-based settings. [ Providers shall be reimbursed only for the amount and type of supported living residential service that is included in the individual's ISP. ] Supported living residential service shall be authorized for Medicaid reimbursement in the plan for supports only when the individual requires this service. This service shall include a skills development component along with the provision of supports, as needed. Supported living residential service shall be covered in the FIS and CL waivers.
B. Criteria and allowable activities.
1. Skill-building and routine supports related to ADLs and IADLs;
2. Skill-building and routine and safety supports related to the use of community resources such as transportation, shopping, restaurant dining, and participating in social and recreational activities. The cost of participation in the actual social or recreational activity shall not be reimbursed;
3. Supporting the individual in replacing challenging behaviors with positive, accepted behaviors for home and community-based environments;
4. Monitoring and supporting the individual's health and physical conditions and providing supports with medication or other medical needs;
5. Providing routine supports and safety supports with transportation to and from community locations and resources;
6. Providing general supports as needed; and
7. Providing safety supports to ensure the individual's health and safety.
C. Service units and limits.
1. The unit of service shall be one day and billing shall not exceed 344 days per ISP year.
2. Total billing shall not exceed the amount authorized in the ISP. [ The provider shall maintain progress note documentation of the dates that service has been provided and of specific circumstances that prevented provision of all of the scheduled service, should that occur. ] This service shall be provided on an individual-specific basis according to the ISP and service setting requirements.
3. Supported living residential service shall not be provided to any individual who receives personal assistance service or other residential service under the FIS or CL waiver, such as group home residential service, shared living service, in-home support service, or sponsored residential service that provide a comparable level of care.
4. Room and board shall not be components of supported residential service.
5. Supported living residential service shall not be used solely to provide routine or emergency respite care for the individual's family/caregiver with whom the individual lives.
6. Medicaid reimbursement shall be available only for supported living residential service when the individual receives supports from the plan of supports and when an enrolled Medicaid provider is providing the service.
7. Supported living residential service shall be a tiered service for reimbursement purposes. Providers shall only be reimbursed for the individual's assigned level and tier.
8. Supported living residential service shall be provided to the individual in the form of around-the-clock availability of paid provider staff who have the ability to respond in a timely manner. This service may be provided individually or simultaneously to more than one individual living in the apartment, depending on the required supports.
D. Provider requirements.
1. The provider shall be licensed by DBHDS as a provider of supervised residential service or supportive in-home service.
2. The provider shall also be currently enrolled with DMAS as a [ providers provider ]. The provider designated on the provider participation agreement shall render this service and submit claims to DMAS for reimbursement.
3. Providers shall ensure that staff providing supported living residential service meets provider [ competency ] training [ and competency ] requirements as specified in 12VAC30-122-180.
4. [ A supervisor meeting the requirements of 12VAC35-105 shall provide supervision of direct support professional staff. Documentation of supervision shall be completed, signed by the staff person designated to perform the supervision and oversight, and shall include the following: Supervision of direct support staff shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight. ]
[ a. Date of contact or observation;
b. Person contacted or observed;
c. A summary about direct support professional staff performance and service delivery;
d. Any action planned or taken to correct problems identified during supervision and oversight; and
e. Documentation of observations, on a semiannual basis by the supervisor, concerning the individual's satisfaction with service provision. ]
5. Supported living residential service shall comply with the HCBS settings requirements when provided in DBHDS licensed settings per 42 CFR 441.301. [ In these settings, lease or residency agreements shall comply with and support individual choice of service and setting. ]
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. A copy of the completed, standard, age-appropriate assessment form as detailed in 12VAC30-122-200.
b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
c. [ Progress note documentation confirming the amount of the individual's time in service and providing specific information regarding the individual's responses to various settings and supports. Observations of the individual's responses to service shall be available in at least a daily note. Documentation as detailed in 12VAC30-122-120. ] Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, then clearly documented in the progress notes or supports checklist.
d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.
e. A written review supported by documentation in the individuals' record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified. [ For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented. ]
f. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
g. Written documentation of contacts made with the individual's family/caregiver, physicians, providers, and all professionals concerning the individual.
2. Documentation shall be provided upon request to DMAS.
3. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-550. Therapeutic consultation service.
A. Service description. Therapeutic consultation service means professional consultation provided by members of psychology, social work, rehabilitation engineering, [ behavioral behavior ] analysis/consultation, speech-language pathology therapy, occupational therapy, psychiatry, psychiatric clinical nursing, therapeutic recreation, or physical therapy disciplines that are designed to assist individuals, parents, guardians, family members, and any other providers of support services with implementing the individual support plan. This service shall provide assessments, development of a therapeutic consultation support plan, and teaching in any of these designated specialty areas to assist family members, caregivers, and other providers in supporting the individual enrolled in the waiver. The individual's therapeutic consultation service support plan shall clearly reflect the individual's needs, as documented in the assessment information, for specialized consultation provided to family/caregivers and providers. Therapeutic consultation service shall be covered in the FIS and CL waivers.
A therapeutic consultation service support plan is the report of recommendations resulting from a therapeutic consultation that is developed by the professional consultant after he spends time with the individual to determine the individual's needs in his area of expertise.
B. Criteria and allowable activities.
1. To qualify for therapeutic consultation service, the individual shall have a documented need for consultation. Documented need shall indicate that the ISP cannot be implemented effectively and efficiently without such consultation as provided by this covered service and approved through service authorization. The need for this service shall be based on the individual's ISP and shall be provided to an individual for whom specialized consultation is clinically necessary. Therapeutic consultation service may be provided in individuals' homes and in appropriate community settings, such as licensed or approved homes or day support programs, as long as they are intended to facilitate implementation of individuals' desired outcomes as identified in their ISP.
2. Allowable activities for this service shall include:
a. Interviewing the individual, family members, caregivers, and relevant others to identify issues to be addressed and desired outcomes of consultation;
b. Observing the individual in daily activities and natural environments and observing and assessing the current interventions, support strategies, or assistive devices being used with the individual;
c. Assessing the individual's need for an assistive device for a modification or adjustment of an assistive device, or both, in the environment or service, including reviewing documentation and evaluating the efficacy of assistive devices and interventions identified in the therapeutic consultation plan;
d. Developing data collection mechanisms and collecting baseline data as appropriate for the type of consultation service provided;
e. Designing a written therapeutic consultation plan [ or a behavioral support plan ] detailing the interventions, environmental adaptations, and support strategies to address the identified issues and desired outcomes, including recommendations related to specific devices, technology, or adaptation of other training programs or activities. The plan may recommend training relevant persons to better support the individual simply by observing the individual's environment, daily routines, and personal interactions;
f. Demonstrating (i) specialized, therapeutic interventions; (ii) individualized supports; or (iii) assistive devices;
g. Training family/caregivers and other relevant persons to assist the individual in using an assistive device; to implement specialized, therapeutic interventions; or to adjust currently utilized support techniques;
h. Intervening directly, by behavioral consultants, with the individual and demonstrating to family/caregivers or staff such interventions. Such intervention modalities shall relate to the individual's identified behavioral needs as detailed in established specific goals and procedures set out in the ISP; and
i. Consulting related to person centered therapeutic outcomes, in person [ or, ] over the phone [ , or via video feed consistent with in accordance with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) ].
C. Service units and limits.
1. The unit of service shall be one hour.
2. The [ servics services ] shall be explicitly detailed in the plan for supports.
3. Travel time [ , and ] written preparation [ , and telephone communication ] shall be considered as in-kind expenses within therapeutic consultation service and shall not be reimbursed as separate items.
4. Therapeutic consultation shall not be billed solely for purposes of monitoring the individual.
5. [ Behavioral consultation. ]
[ a. ] Only behavioral consultation in the therapeutic consultation service may be offered in the absence of any other waiver service.
[ b. Initial requests for behavioral consultation may not be authorized for more than 180 days.
c. Behavioral support plans will be submitted with subsequent authorizations as well as baseline data for the initial request after assessment and then an annual summary of quarterly data for re-renewals. ]
6. Other than behavioral consultation, therapeutic consultation service shall not include direct therapy provided to individuals enrolled in the waiver and shall not duplicate the activities of other services that are available to the individual through the State Plan for Medical Assistance. Behavior consultation may include direct behavioral interventions and demonstration of such interventions to family members or staff.
D. Provider requirements. Professionals rendering therapeutic consultation service, including behavior consultation, shall meet all applicable state licensure or certification requirements.
1. Behavior consultation shall only be provided by (i) a [ board-certified behavioral licensed behavior ] analyst or a [ board-certified associate licensed assistant ] behavior analyst or (ii) a positive [ behavioral behavior ] supports facilitator endorsed by a recognized positive [ behavioral behavior ] supports organization or who meets the criteria for psychology consultation.
2. Psychology consultation shall only be provided by the following individuals licensed in the Commonwealth of Virginia: (i) a psychologist, (ii) a licensed professional counselor, (iii) a licensed clinical social worker, (iv) a psychiatric clinical nurse specialist, or (v) a psychiatrist.
3. Speech consultation shall only be provided by a speech-language pathologist who is licensed by the Commonwealth of Virginia.
4. Occupational therapy consultation shall only be provided by an occupational therapist who is licensed by the Commonwealth of Virginia.
5. Physical therapy consultation shall only be provided by a physical therapist who is licensed by the Commonwealth of Virginia.
6. Therapeutic recreation consultation shall only be provided by a therapeutic recreation specialist who is certified by the National Council for Therapeutic Recreation Certification.
7. Rehabilitation consultation shall only be provided by a rehabilitation engineer or certified rehabilitation specialist.
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. A copy of the completed age-appropriate assessment as detailed in 12VAC30-122-200.
b. [ A plan for support, that contains at a minimum the following elements:
(1) Identifying information;
(2) Desired outcomes, support activities, and timeframes; and
(3) Specific consultation activities. The provider's plan for supports per requirements detailed in 12VAC30-122-120. ]
c. A written therapeutic consultation support plan detailing the recommended interventions or support strategies for providers and family/caregivers to better support the individual enrolled in the waiver in the service.
[ (1) Behavior support plans will contain the following information, at a minimum: (i) demographic information, (ii) person-centered information, (iii) history and rationale, (iv) functional behavior assessment, (v) behaviors targeted for decrease, (vi) hypothesized functions of behavior, (vii) proactive strategies and antecedent interventions, (viii) replacement behaviors and behaviors targeted for increase; (ix) consequence interventions (when indicated), (x) safety and crisis guidelines (when indicated), (xi) any additional recommendations (linkages, etc.), and (xii) appropriate signatures and plan for training.
(2) Documentation of who was trained on the plan and when and where should be maintained and a plan for ongoing training should be determined. ]
d. Ongoing progress note documentation of rendered consultative service that may be in the form of contact-by-contact or monthly notes that must be contemporaneously signed and dated, that identify each contact [ including location and recipient of training activities ], the amount of time spent on the activity, what was accomplished, and the professional who made the contact and rendered the service.
e. If the consultation service extends three months or longer, written quarterly reviews that are completed by the provider and forwarded to the support coordinator. If the consultation service extends beyond one year or when there are changes to the plan for supports, the plan for supports shall be reviewed by the provider with the individual, individual's family/caregiver, as appropriate, and the support coordinator and shall be submitted to the support coordinator for service authorization, as appropriate.
[ (1) For behavioral therapeutic consultation, the quarterly review shall include graphed data and a summary of this data.
(2) For behavioral therapeutic consultation, the annual review shall include graphed or tabled data that is trended across the first three quarters. ]
f. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
g. Written progress note documentation of contacts made with the individual's family/caregiver, physicians, providers, and all professionals concerning the individual.
h. A contemporaneously signed and dated final disposition summary that is forwarded to the support coordinator within 30 days following the end of this service and that includes:
(1) Strategies utilized;
(2) Objectives met;
(3) Unresolved issues; and
(4) Consultant recommendations.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
12VAC30-122-560. Transition service.
A. Service description. Transition service shall be consistent with the requirements and limits set out in 12VAC30-120-2010.
B. Criteria and allowable required activities. This service shall be the same as set out in [ 12VAC30-120-2000 and ] 12VAC30-120-2010.
C. Service units and limits shall be the same as those set out in [ 12VAC30-120-2000 and ] 12VAC30-120-2010.
D. Provider requirements shall be the same as those set out in [ 12VAC30-120-2000 and ] 12VAC30-120-2010. All transition service provided in this waiver shall be reimbursed consistent with the agency's service limits and payment amounts as set out in the fee schedule.
E. Service documentation and requirements shall be the same as those set out in [ 12VAC30-120-2000 and ] 12VAC30-120-2010.
F. Transition service is covered in the FIS, CL, and BI waivers.
12VAC30-122-570. Workplace assistance service.
A. Service description. Workplace assistance service means supports provided to an individual who has completed job development and completed or nearly completed job placement training (i.e., individual supported employment) but requires more than the typical job coach services, as in 12VAC30-122-400, to maintain stabilization in his employment. This service is supplementary to individual supported employment service. Workplace assistance service shall be covered in the FIS and CL waivers.
B. Criteria and allowable activities.
1. The activity shall not be work skills training that would normally be provided by a job coach.
2. [ The This ] service shall be delivered in their natural employment setting, where and when [ they are the service is ] needed.
3. The service shall facilitate the maintenance [ of ] and inclusion [ of the individual ] in an employment situation.
4. Allowable activities include:
a. Habilitative supports related to nonwork skills needed for the individual to maintain employment such as appropriate behavior, health maintenance, time management, or other skills without which the individual's continued employment would be endangered;
b. Habilitative supports needed to make and strengthen community connections;
c. Routine supports with personal care needs; however, this cannot be the sole use of workplace assistance service; and
d. Safety supports needed to ensure the individual's health and safety.
C. Service units and limits.
1. A unit shall be one hour. Workplace assistance service may be provided during the time that the individual being served is working, up to and including 40 hours a week. There shall be no annual limit on how long this service may remain authorized.
2. Workplace assistance service shall not be provided simultaneously (i.e., the same dates and times) with work-related personal assistance service. This service shall not be provided solely for the purpose of providing assistance with ADLs to the individual when the individual is working.
3. The service delivery ratio shall be one staff person to one waiver individual.
4. The combination of workplace assistance service, community engagement service, community coaching service, supported employment service, and group day service shall not exceed 66 hours per week.
5. Workplace assistance service can be provided simultaneously with individual supported employment (ISE) service to ensure that the workplace assistant is trained and supervised appropriately in supporting the individual through ISE best practices.
D. Provider requirements. Providers shall meet the following requirements:
1. Providers shall be either:
a. Providers of supported employment services with DARS. DARS shall verify that these providers meet criteria to be providers through a DARS-recognized accrediting body. DARS shall provide the documentation of this accreditation verification to DMAS and DBHDS upon request.
(1) DARS-contracted providers shall maintain their accreditation in order to continue to receive Medicaid reimbursement.
(2) DARS-contracted providers that lose their accreditation, regardless of the reason, shall not be eligible to receive Medicaid reimbursement and shall have their provider agreement terminated by DMAS. Reimbursements made to such providers after the date of the loss of the accreditation shall be subject to recovery by DMAS; or
b. Licensed by DBHDS as a provider of non-center-based day support service.
2. These providers shall hold current provider participation agreements with DMAS. The provider designated on the signed agreement shall submit claims to DMAS for reimbursement and shall maintain the required documentation that supports the claims submitted for reimbursement.
3. Providers shall ensure that staff providing workplace assistance service meet provider [ competency ] training [ and competency ] requirements as specified in 12VAC30-122-180. In addition, prior to seeking reimbursement for this service from DMAS, these providers shall ensure that staff providing workplace assistance service have completed training regarding the principles of supported employment. The documentation of the completion of this training shall be maintained by the provider and shall be provided to DMAS and DBHDS upon request.
4. The direct support professional providing workplace assistance service shall coordinate his service provision with the job coach if there is one working with the individual providing individual supported employment service to the individual being supported.
[ 5. Supervision of direct support staff shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight. ]
E. Service documentation and requirements.
1. Providers shall include signed and dated documentation of the following in each individual's record:
a. A copy of the completed age-appropriate assessment as detailed in 12VAC30-122-200.
b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.
c. [ Provider documentation confirming the individual's amount of time in service and providing specific information regarding the individual's response to various settings and supports as agreed to in the plan for supports. This documentation shall be available in at least a daily note or a weekly summary. Documentation as detailed in 12VAC30-122-120. ] Data shall be collected as described in the plan for supports, reviewed, summarized, and included in the regular progress note supporting documentation.
d. A written review supported by documentation in the individuals' record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified. [ For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented. ]
e. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.
f. Written progress note documentation of contacts made with the individual's family/caregiver, physicians, providers, and all professionals concerning the individual.
2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.
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 (12VAC30-122)
Supports Intensity Scale - Adult VersionTM (ages 16 and up), SIS-A, copyright 2015, American Association on Intellectual and Developmental Disabilities
Supports Intensity Scale - Children's VersionTM (ages 5-16), SIS-C, copyright 2016, American Association on Intellectual and Developmental Disabilities
Virginia Supplemental Questions (eff. 10/2014)
Skill Competencies for Professionals and Direct Support Staff in Virginia Supporting Adolescents and Adults with Autism, developed by Virginia Autism Council, June 1, 2014, DMAS-P201 (filed 1/2019)
Medicaid Long-Term Care Communication Form, DMAS-225 (rev. 12/2015)
Virginia Individual Developmental Disabilities Eligibility Survey - Infants' Version, DMAS-P235 (eff. 3/2016)
Virginia Individual Developmental Disabilities Eligibility Survey - Children's Version, DMAS-P236 (eff. 4/2016)
Virginia Individual Developmental Disabilities Eligibility Survey - Adult Version, DMAS-P237 (eff. 3/2016)
Behavioral Support Competencies for Direct Support Providers and Professionals in Virginia Supporting Individuals with Developmental Disabilities, developed by the Virginia Department of Behavioral Health and Developmental Services, August 2015, DMAS-P240a (filed 1/2019)
Virginia's Competencies for Direct Professionals and Supervisors Who Support Individuals with Developmental Disabilities - DSP and Supervisor's Competencies Checklist, DMAS-P241a (eff. 6/2016)
Direct Support Professional Assurance for Non-DBHDS-Licensed Providers to Confirm Successful Completion of Testing and Competency Requirements for the DD Waivers, DMAS-P243a (eff. 6/2016)
Virginia's Health Competencies for Direct Support Professionals and Supervisors Who Support Individuals with Developmental Disabilities - Health Competencies Checklist, DMAS-P244a (eff. 6/2016)
Supervisor Assurance for DBHDS-licensed Providers to Confirm Successful Completion of Training, Testing, and Competency Requirements for the DD Waivers, DMAS-P245a (eff. 7/2016)
Supervisor Assurance for Non-DBHDS-Licensed Services to Confirm Successful Completion of Training and Testing Requirements for the DD Waivers, DMAS-P245a (eff. 7/2016)
[ Community Housing Guide: Housing Road Map (form date 10/2019)
Community Housing Guide: Tenant Screening (form date 10/2019)
FIS Request for Supervision Hours in Personal Assistance, DMAS-P257 (05/28)
CL Request for Supervision Hours in Personal Assistance, DMAS-P257 (05/28) ]
VA.R. Doc. No. R17-4614; Filed February 05, 2021