Title of Regulation: 22VAC30-110. Assessment in Assisted Living Facilities (amending 22VAC30-110-10 through 22VAC30-110-50, 22VAC30-110-80 through 22VAC30-110-110).

Statutory Authority: §§ 51.5-131 and 51.5-146 of the Code of Virginia.

Effective Date: June 9, 2021.

Agency Contact: Paige McCleary, Adult Services Program Consultant, Department for Aging and Rehabilitative Services, 8004 Franklin Farms Drive, Richmond, VA 23229, telephone (804) 662-7605, or email paige.mccleary@dars.virginia.gov.

Summary:

The amendments (i) permit the use of video conferencing for assessments when there are hazardous travel conditions or the individual to be assessed is in another state, (ii) specify that qualified assessors who are employees of local departments of social services shall enter assisted living facility assessments in the case management system designated by the department, (iii) specify that the earliest date that an annual reassessment may be completed is 60 calendar days prior to the annual reassessment due date, (iv) require that qualified assessors and case managers make housing options clear, (v) no longer require that qualified assessors and case managers advise public pay individuals of the outcome of the assessment or the annual reassessment orally and in writing, and (vi) amend other language for improved clarity.

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

22VAC30-110-10. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Activities of daily living" or "ADLs" means bathing, dressing, toileting, transferring, bowel control, bladder control, and eating/feeding. An individual's degree of independence in performing these activities is a part of determining appropriate level of care and services.

"Administrator" means the licensee or person designated by the licensee who (i) is responsible for the general administration and management of an assisted living facility and who oversees the day-to-day operation of the facility, including compliance with all regulations for assisted living facilities and (ii) meets the requirements of 22VAC40-72.

"Assessment" means a standardized approach using common definitions to gather sufficient information about an individual applying to or residing in an assisted living facility to determine the need for appropriate level of care and services.

"Assisted living care" means a level of service provided by an assisted living facility to individuals who may have physical or mental impairments and require at least moderate assistance with the activities of daily living. Moderate assistance means dependency in two or more of the activities of daily living. Included in this level of service are individuals who are dependent in behavior pattern (i.e., abusive, aggressive, disruptive) as documented on the uniform assessment instrument.

"Assisted living facility" or "ALF" means any public or private ALF that is required to be licensed as an ALF by the Department of Social Services under Chapter 17 (§ 63.2-1700 et seq.) of Title 63.2 of the Code of Virginia, specifically, any congregate residential setting that provides or coordinates personal and health care services, 24-hour supervision, and assistance (scheduled and unscheduled) for the maintenance or care of four or more adults who are aged, infirm, or disabled and who are cared for in a primarily residential setting, except (i) a facility or portion of a facility licensed by the State Board of Health or the Department of Behavioral Health and Developmental Services, but including any portion of such facility not so licensed; (ii) the home or residence of an individual who cares for or maintains only persons related to him by blood or marriage; (iii) a facility or portion of a facility serving infirm or disabled persons between the ages of 18 and 21 years, or 22 years if enrolled in an educational program for the handicapped pursuant to § 22.1-214 of the Code of Virginia, when such facility is licensed by the Department of Social Services as a children's residential facility under Chapter 17 (§ 63.2-1700 et seq.) of Title 63.2 of the Code of Virginia, but including any portion of the facility not so licensed; and (iv) any housing project for persons 62 years of age or older or the disabled that provides no more than basic coordination of care services and is funded by the U.S. Department of Housing and Urban Development, by the U.S. Department of Agriculture, or by the Virginia Housing Development Authority. Included in this definition are any two or more places, establishments or institutions owned or operated by a single entity and providing maintenance or care to a combined total of four or more aged, infirm, or disabled adults. Maintenance or care means the protection, general supervision, and oversight of the physical and mental well-being of an aged, infirm, or disabled individual. Assuming responsibility for the well-being of individuals, either directly or through contracted agents, is considered general supervision and oversight.

"Auxiliary Grants Program" means a state and locally funded assistance program to supplement the income of an individual who is receiving Supplemental Security Income (SSI) or an individual who would be eligible for SSI except for excess income, and who resides in an ALF with an approved rate, an adult foster care home, or supportive housing setting with an established rate [ in ] the [ annual appropriations act Appropriation Act ]. The total number of individuals within the Commonwealth of Virginia eligible to receive auxiliary grants in a supportive housing setting shall not exceed the number individuals designated in the [ annual appropriations act Virginia law ] and the signed agreement between the department and the Social Security Administration.

"Case management" means multiple functions designed to link individuals to appropriate services. Case management may include a variety of common components such as initial screening of need, comprehensive assessment of needs, development and implementation of a plan of care, service monitoring, and follow-up.

"Case management agency" means a public human service agency which employs a case manager or contracts for case management.

"Case manager" means an employee of a public human services agency who is qualified to perform assessments and to develop and coordinate plans of care.

"Department" or "DARS" means the Virginia Department for Aging and Rehabilitative Services.

"Department designated case management system" means the official state automated computer system that collects and maintains information on assessments conducted by employees of the local department who meet the definition of qualified assessor.

"Dependent" means, for ADLs and instrumental activities of daily living (IADLs), the individual needs the assistance of another person or needs the assistance of another person and equipment or a device to safely complete the activity an ADL or IADL. For medication administration, dependent means the individual needs to have medications administered or monitored by another person or professional staff. For behavior pattern, dependent means the individual's behavior is aggressive, abusive, or disruptive.

"Discharge" means the process that ends an individual's stay in the ALF.

"Emergency placement" means the temporary status of an individual in an ALF when the individual's health and safety would be jeopardized by not permitting denying entry into the facility until requirements for admission have been met.

"Face-to-face" means interacting with an individual in need of an assessment in a manner that enables the qualified assessor or case manager to observe the individual's behavior and ability to perform ADLs and IADLs.

"Facility" means an ALF.

"Independent physician" means a physician who is chosen by an individual residing in the ALF and who has no financial interest in the ALF, directly or indirectly, as an owner, officer, or employee or as an independent contractor with the facility.

"Instrumental activities of daily living" or "IADLs" means for the purposes of this chapter, meal preparation, housekeeping, laundry, and money management. An individual's degree of independence in performing these activities is a part of determining appropriate level of care and services.

"Local department" means any local department of social services in the Commonwealth of Virginia.

"Maximum physical assistance" means that an individual has a rating of total dependence in four or more of the seven activities of daily living as documented on the uniform assessment instrument.

"Medication administration" means for purposes of this chapter, assessing the degree of assistance an individual requires to take medications in order to determine the individual's appropriate level of care.

"Minimal assistance" means dependency in only one ADL or dependency in one or more IADLs as documented on the uniform assessment instrument. Included in this level of services are individuals who are dependent in medication administration as documented on the UAI.

"Moderate assistance" means dependency in two or more ADLs as documented on the UAI.

"Private pay" means that an individual residing in an assisted living facility ALF is not eligible for benefits under the Auxiliary Grants Program.

"Prohibited conditions" means physical or mental health conditions or care needs as described in § 63.2-1805 of the Code of Virginia. An ALF shall not admit or allow the continued residence of an individual with a prohibited condition. Prohibited conditions include, but are not limited to, an individual who requires maximum physical assistance as documented on the uniform assessment instrument and meets nursing facility level of care criteria as defined in the State Plan for Medical Assistance. Unless the individual's independent physician determines otherwise, an individual who requires maximum physical assistance and meets nursing facility level of care criteria as defined on the State Plan for Medical Assistance shall not be admitted to or continue to reside in an ALF.

"Public human services agency" means an agency established or authorized by the General Assembly under Chapters 2 and 3 (§§ 63.2-200 et seq. and 63.2-300 et seq.) of Title 63.2, Chapter 14 (§ 51.5-116 et seq.) of Title 51.5, Chapters 1 and 5 (§§ 37.2-100 et seq. and 37.2-500 et seq.) of Title 37.2, or Article 5 (§ 32.1-30 et seq.) of Chapter 1 of Title 32.1, or hospitals operated by the state under Chapters 6.1 and 9 (§§ 23-50.4 et seq. and 23-62 et seq.) of Title 23 of the Code of Virginia and supported wholly or principally by public funds, including but not limited to funds provided expressly for the purposes of case management.

"Public pay" means that an individual residing in an ALF is eligible for benefits under the Auxiliary Grants Program.

"Qualified assessor" means a person who is authorized to perform an assessment, reassessment, or change in level of care for an individual who is seeking admission to an ALF or who resides in an ALF. For public pay individuals, a qualified assessor is an employee of a public human services agency who is trained in the completion of the uniform assessment instrument and is authorized to approve placement for an individual who is seeking admission to or residing in an ALF. For private pay individuals, a qualified assessor is staff of the ALF trained in the completion of the uniform assessment instrument or an independent physician or a qualified assessor for public pay individuals.

"Reassessment" means an update of information on the uniform assessment instrument at any time UAI after the initial assessment. In addition to an annual reassessment, a reassessment shall be completed whenever there is a significant change in the individual's condition.

"Residential living care" means a level of service provided by an ALF for individuals who may have physical or mental impairments and require only minimal assistance with the activities of daily living. Minimal assistance means dependency in only one ADL or dependency in one or more of the selected IADLs as documented on the uniform assessment instrument. Included in this level of service are individuals who are dependent in medication administration as documented on the uniform assessment instrument. The definition of residential living care includes the services provided by the ALF to individuals who are assessed as capable of maintaining themselves in an independent living status.

"Significant change" means a change in an individual's condition that is expected to last longer than 30 days. It does not include short-term changes that resolve with or without intervention, a short-term acute illness or episodic event, or a well-established, predictive, cyclic pattern of clinical signs and symptoms associated with a previously diagnosed condition where an appropriate course of treatment is in progress.

"Targeted case management" means the provision of ongoing case management services by an employee of a public human services agency contracting with the Department of Medical Assistance Services to an individual who is receiving an auxiliary grant in an ALF who meets the criteria set forth in 12VAC30-50-470.

"Total dependence" means the individual is entirely unable to participate in the performance of an ADL.

"Uniform assessment instrument" or "UAI" means the department-designated assessment form. There is an alternate version of the uniform assessment instrument that may be used for individuals paying privately to reside in the ALF. Social and financial information that is not relevant because of the individual's payment status is not included on the private pay version.

"User's Manual: Virginia Uniform Assessment Instrument" means the department-designated handbook containing common definitions and procedures for completing the department-designated assessment form.

"Virginia Department of Medical Assistance Services" or "DMAS" means the single state agency designated to administer the Medical Assistance Services Program in Virginia.

22VAC30-110-20. Individuals to be assessed.

A. All individuals applying to or residing in an ALF shall be assessed face-to-face using the UAI prior to admission, at least annually, and whenever there is a significant change in the individual's condition.

1. When the qualified assessor or case manager and individual are unable to be in the same physical space to conduct an assessment due to the individual's location in another state or due to hazardous travel conditions for the qualified assessor or case manager, the use of video conferencing to conduct the assessment shall be permitted.

2. The appropriate qualified assessor or case manager shall review the assessment with the adult within seven working days of admission to the ALF to ensure all assessment information is accurate.

B. For private pay individuals, qualified staff of the ALF or an independent physician may complete the UAI. Qualified staff are ALF employees who have successfully completed state-approved department designated training course on the UAI for either public or private pay assessments. The ALF maintains documentation of the completed training. The administrator or the administrator's designated representative shall approve and sign the completed UAI for private pay individuals. A private pay individual may request the assessment be completed by a qualified public human services agency assessor. When a public human services agency assessor completes the UAI for a private pay individual, the agency may determine and charge a fee for private pay assessments that may not exceed the amount DMAS reimburses for public pay assessments.

C. For public pay individuals, the UAI shall be completed by a case manager or a qualified assessor to determine the need for residential care or assisted living care services. The assessor is qualified to complete the assessment if the assessor has completed a state-approved the department designated training course on the UAI. Assessors who prior to January 1, 2004, routinely completed UAIs as part of their job descriptions may be deemed to be qualified assessors without the completion of the training course. Qualified assessors who may initially authorize ALF services for public pay individuals are employees of:

1. Local departments of social services;

2. Area agencies on aging;

3. Centers for independent living;

4. Community services boards or behavioral health authorities;

5. Local departments of health;

6. State facilities operated by the Department of Behavioral Health and Developmental Services;

7. Acute-care hospitals;

8. Department of Corrections; and

9. Independent physicians who have a contract signed provider agreement with DMAS to conduct ALF assessments.

D. For public pay individuals, the ALF shall coordinate with the qualified assessor or case manager to ensure that the UAI is completed as required. If the individual has not been assessed, the local department of social services eligibility benefits worker shall inform the individual or the individual's legal representative of the need to be assessed by a qualified assessor prior to admission. If the individual has not applied for an auxiliary grant, the qualified assessor or case manager conducting the assessment shall inform the individual or the individual's legal representative of the need to submit an application for an auxiliary grant.

22VAC30-110-30. Determination of services to be provided.

A. The assessment shall be conducted using the UAI that sets forth an individual's care needs. The UAI is designed to be a comprehensive, accurate, standardized, and reproducible assessment of individuals seeking or receiving long-term care services. The UAI is comprised of a short assessment and a full assessment. The short assessment is designed to briefly assess the individual's need for appropriate level of care and services and to determine if a full assessment is needed.

B. The following sections of the UAI shall be completed as follows:

1. For private pay individuals, the assessment shall include sections related to identification and background, functional status, which includes ADLs, continence, ambulation, IADLs, medication administration, and behavior pattern. The private pay or public pay UAI may be used.

2. For public pay individuals, the short form of the UAI shall be completed. The short form consists of sections related to identification and background, and functional status (i.e., the first four pages of the UAI), plus sections on medication administration, and behavior pattern. If, upon assessment, it is determined that the individual is dependent in at least two ADLs or is dependent in behavior, then the full assessment shall be completed.

3. For private pay and public pay individuals, the prohibited conditions section shall be completed.

C. The UAI shall be completed within 90 days prior to the date of admission to the ALF. If there has been a significant change in the individual's condition since the completion of the UAI that would affect the admission to an ALF, a new UAI shall be completed as specified in 22VAC30-110-20.

D. When an individual moves to an ALF from another ALF, a new UAI is not required except that a new UAI shall be completed whenever there is a significant change in the individual's condition or the assessment most recent UAI was completed more than 12 months ago.

E. In emergency placements, the UAI shall be completed within seven working days from the date of placement. An emergency placement shall occur only when the emergency is documented and approved by (i) a Virginia local department adult protective services worker for public pay individuals or by (ii) a Virginia local department adult protective services worker or independent physician for private pay individuals.

F. The UAI shall be completed annually on all individuals residing in ALFs and whenever there is a significant change in the individual's condition. UAIs shall be completed whenever there is a significant change in the individual's condition. All UAIs shall be completed as required by 22VAC30-110-20. The ALF shall provide an area for assessments and reassessment to be conducted that ensures the individual's privacy and protects confidentiality.

G. The ALF shall provide an area for assessments and reassessment to be conducted that ensures the individual's privacy and protects confidentiality.

H. At the request of the ALF, the individual residing in the ALF, the individual's legal representative, the individual's physician, the Virginia Department of Social Services, or the local department of social services, an independent assessment using the UAI shall be completed to determine whether the individual's care needs are being met in the current ALF. An independent assessment is an assessment that is completed by an entity other than the original assessor. The ALF shall assist the individual in obtaining the independent assessment as requested. If the request is for a private pay individual, the entity requesting the independent assessment shall be responsible for paying for the assessment.

H. I. The assessor shall consult with other appropriate human service professionals as needed to complete the assessment.

J. Qualified assessors who are employees of local departments shall enter ALF assessments in the department designated case management system.

I. K. DMAS shall reimburse for completion of assessments and authorization of ALF placement for public pay individuals pursuant to this section.

22VAC30-110-40. Discharge.

A. ALF staff shall assist the individual and the individual's legal representative in the discharge or transfer process. For public pay individuals, ALF staff shall provide written notification of the individual's date and place of discharge or of the individual's death to the local department of social services eligibility benefits worker in the jurisdiction responsible for authorizing the auxiliary grant and the qualified assessor or case manager who conducted the most recent assessment. The ALF shall make these notifications at least 14 calendar days prior to the individual's planned discharge or within five calendar days after the individual's death. In the event of an emergency discharge as specified in 22VAC40-72-420 22VAC40-73-430, the notification shall be made as rapidly as possible, but must be made by close of business on the day following the emergency discharge.

B. Upon issuing a notice of summary order of suspension to an ALF, the Commissioner of the Virginia Department of Social Services or his designee shall contact the appropriate local department of social services to develop a relocation plan. Individuals residing in an ALF whose license has been summarily suspended pursuant to § 63.2-1709 of the Code of Virginia shall be relocated as soon as possible to reduce the risk to their health, safety, and welfare. New assessments of the individuals who are relocating are not required, pursuant to 22VAC30-110-30 D.

22VAC30-110-50. Authorization of services to be provided.

A. The qualified assessor or case manager is responsible for authorizing public payment to the individual for the appropriate level of care upon admission to and for continued stay in an ALF.

B. The ALF staff shall be knowledgeable of the criteria for level of care in an ALF and are responsible for discharging the individual when the individual does not meet the criteria for level of care in an ALF upon admission or at any later time.

C. The appropriate level of care shall be documented on the UAI, and the UAI shall be completed in a manner consistent with the definitions of ADLs and directions provided in the this chapter. The User's Manual: Virginia Uniform Assessment Instrument as well as the requirements set forth in this chapter is the department-designated handbook containing procedures that may be used in completing the UAI.

D. During an inspection or review, staff from the Virginia Department of Social Services or the local department of social services may initiate a change in level of care for any individual residing in the ALF for whom it is determined that the UAI does not reflect the individual's current status.

22VAC30-110-80. Rating of levels of care on the uniform assessment instrument.

A. The rating of functional dependencies on the UAI shall be based on the individual's ability to function in a community environment.

B. For purposes of this chapter, the following abbreviations shall mean: D = dependent; and TD = totally dependent. Mechanical help means equipment or a device or both are used; human help includes supervision and physical assistance. Asterisks (*) denote dependence in a particular function.

1. Activities of daily living.

a. Bathing.

(1) Without help

(2) Mechanical help only

(3) Human help only* (D)

(4) Mechanical help and human help* (D)

(5) Is performed Performed by others* (TD)

b. Dressing.

(1) Without help

(2) Mechanical help only

(3) Human help only* (D)

(4) Mechanical help and human help* (D)

(5) Is performed Performed by others* (TD)

(6) Is not performed* (TD)

c. Toileting.

(1) Without help

(2) Mechanical help only

(3) Human help only* (D)

(4) Mechanical help and human help* (D)

(5) Performed by others* (TD)

(6) Is not performed* (TD)

d. Transferring.

(1) Without help

(2) Mechanical help only

(3) Human help only* (D)

(4) Mechanical help and human help* (D)

(5) Is performed Performed by others* (TD)

(6) Is not performed* (TD)

e. Bowel function.

(1) Continent

(2) Incontinent less than weekly

(3) Ostomy self-care

(4) Incontinent weekly or more* (D)

(5) Ostomy not self-care* (TD)

f. Bladder function.

(1) Continent

(2) Incontinent less than weekly

(3) External device, indwelling catheter, ostomy, self-care

(4) Incontinent weekly or more* (D)

(5) External device, not self-care* (TD)

(6) Indwelling catheter, not self-care* (TD)

(7) Ostomy, not self-care* (TD)

g. Eating/feeding.

(1) Without help

(2) Mechanical help only

(3) Human help only* (D)

(4) Mechanical help and human help* (D)

(5) Performed by others (includes spoon fed, syringe/tube fed, fed by IV)* (TD)

2. Behavior pattern.

a. Appropriate

b. Wandering/passive less than weekly

c. Wandering/passive weekly or more

d. Abusive/aggressive/disruptive less than weekly* (D)

e. Abusive/aggressive/disruptive weekly or more* (D)

3. Instrumental activities of daily living.

a. Meal preparation.

(1) No help needed

(2) Needs help* (D)

b. Housekeeping.

(1) No help needed

(2) Needs help* (D)

c. Laundry.

(1) No help needed

(2) Needs help* (D)

d. Money management.

(1) No help needed

(2) Needs help* (D)

4. Medication administration.

a. Without assistance

b. Administered/monitored by lay person* (D)

c. Administered/monitored by professional staff* (D)

22VAC30-110-90. Actions to be taken upon completion of the uniform assessment instrument.

A. Public Actions to be taken upon completion of the uniform assessment instrument for public pay individuals.

1. Upon completion of the UAI for initial assessment for admission, a significant change in the individual's condition, or the annual reassessment, the case manager or a qualified assessor shall forward to the local department of social services eligibility benefits worker in the appropriate agency of jurisdiction, in the format specified by the department, the effective date of admission or change in level of care. Qualified assessors who are authorized to perform the annual reassessment or a change in level of care for public pay individuals are employees of (i) local departments of social services; (ii) area agencies on aging; (iii) centers for independent living; (iv) community services boards or behavioral health authority; and (v) local departments of health, or an independent physician who has a contract signed provider agreement with DMAS to conduct assessments.

2. The completed A [ completed ] copy of the UAI, the referral to the eligibility local department benefits worker, and other relevant data shall be maintained in the individual's record at the ALF.

3. The annual reassessment shall be completed by the qualified assessor or case manager conducting the initial assessment. If the original assessor is neither willing nor able to complete the assessment and another assessor is not available, the local department of social services where the individual resides in the ALF shall be the assessor, except that individuals who receive services from a community service board or behavioral health authority shall be assessed and reassessed by qualified assessors employed by the community services board or behavioral health authority.

4. The earliest date that an annual reassessment may be completed is 60 calendar days prior to the annual reassessment due date.

5. After the annual reassessment has been completed, if the individual still meets either residential or assisted living level of care, the qualified assessor or case manager shall offer the individual the choice, based on availability, of housing option pursuant to § 51.5-160 of the Code of Virginia.

4. 6. The ALF shall notify the community services board or behavioral health authority when UAIs indicate observed behaviors or patterns of behavior indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders, pursuant to § 63.2-1805 B of the Code of Virginia.

B. For Actions to be taken upon completion of the uniform assessment instrument for private pay individuals, the ALF shall ensure that assessments for all individuals at admission and at subsequent intervals are completed as required in this chapter. The ALF shall maintain the individual's UAI and other relevant data in the individual's ALF record.

22VAC30-110-100. Targeted case management for individuals receiving an auxiliary grant.

A. Targeted case management shall be limited to those individuals who have multiple needs across multiple providers and this coordination is beyond the scope of the ALF. It shall be the responsibility of the qualified assessor or case manager who identifies the individual's need for residential care or assisted living care in an ALF to assess the need for targeted case management as defined in 12VAC30-50-470.

B. A case management agency shall have signed an a provider agreement with DMAS to be reimbursed for the provision of targeted case management for individuals receiving an auxiliary grant.

C. The local department of social services where the individual resides, following admission to an ALF, shall be the case management agency when there is no other qualified case management provider willing or able to provide case management.

D. A qualified case manager shall possess a combination of relevant work experience in human services or health care and relevant education which indicates that the individual possesses the knowledge, skills, and abilities at entry level as defined in 12VAC30-50-470. This must be documented on the case manager's job application form or supporting documentation. When the provider agency is a local department of social services, case managers shall meet the qualifications for family services occupational group as specified in 22VAC40-670-20.

22VAC30-110-110. Notifications.

Assessors Qualified assessors and case managers shall advise orally and in writing provide to all public pay individuals written notice of the outcome of the assessment or the annual reassessment, including a statement indicating that the local department of social services will notify the individual whether he is eligible to receive the auxiliary grant. An individual who is denied an auxiliary grant because the assessor determines that the individual does not meet the care needs for residential level of care has the right to file an appeal with the Virginia Department of Social Services under § 63.2-517 of the Code of Virginia. Notification of the right to appeal will be included in the notice of action provided by the local department of social services. A determination that the individual does not meet the criteria to receive targeted case management is an action that is appealable to DMAS in accordance with the provisions of 12VAC30-110.

DOCUMENTS INCORPORATED BY REFERENCE (22VAC30-110)

User's Manual: Virginia Uniform Assessment Instrument (UAI), Commonwealth of Virginia (rev. 7/05)