Virginia Administrative Code
Title 12 - HEALTH
Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE
Section 12VAC30-60-305 - Screenings in the community and hospitals for Medicaid-funded long-term services and supports
Universal Citation: 2 VA Admin Code 30-60-305
Current through Register Vol. 41, No. 3, September 23, 2024
A. Community screenings for adults.
1. Medical or nursing
and functional eligibility for Medicaid-funded LTSS shall be determined by the
CBT after completion of a screening of the individual's needs and available
supports. The CBT shall consider all the supports available for that individual
in the community (i.e., the immediate family, other relatives, other community
resources), and other services in the continuum of LTSS. The screening shall
be documented on the DMAS-designated forms identified in
12VAC30-60-306.
2. Screenings shall be completed in the
individual's residence unless the residence presents a safety risk for the
individual or the CBT, or unless the individual or the representative requests
that the screening be performed in an alternate location within the same
jurisdiction. The individual shall be permitted to have another person present
at the time of the screening. Other than situations when a court has issued an
order for a screening, the individual shall also be afforded the right to
refuse to participate. The CBT shall determine the appropriate degree of
participation and assistance given by other persons to the individual during
the screening and accommodate the individual's preferences to the extent
feasible.
3. The CBT shall:
a. Observe the individual's ability to
perform appropriate ADLs according to
12VAC30-60-303
and consider the individual's communication or responses to questions or his
representative's communication or responses;
b. Observe, assess, and report the
individual's medical, nursing, and functional condition. This information shall
be used to ensure accurate and comprehensive evaluation of the individual's
need for modification of treatment or additional medical procedures to prevent
destabilization even when the individual has demonstrated an inability to
self-observe or evaluate the need to contact skilled medical
professionals;
c. Identify the
medical or nursing needs, and functional needs of the individual; and
d. Consider services and settings that may be
needed by the individual in order for the individual to safely perform
ADLs.
4. Upon completion
of the screening and in consideration of the communication from the individual
or his representative, if appropriate, and observations obtained during the
screening, the CBT shall determine whether the individual meets the criteria
set out in
12VAC30-60-303.
If the individual meets the criteria for LTSS, the CBT shall inform the
individual or his representative, if appropriate, of this determination in
writing and provide choice of the feasible alternatives, such as PACE or home
and community-based waiver services, to placement in a NF.
5. If waiver services or PACE, where
available, are declined, the reason for declining shall be recorded on the
DMAS-97, Individual Choice - Institutional Care or Waiver Services Form. The
CBT shall have this document signed by either the individual or his
representative, if appropriate. In addition to the electronic document, a paper
copy of the DMAS-97 form with the individual's or his representative's
signature shall be retained in the individual's record by the screening
entity.
6. If the individual meets
criteria and selects home and community-based services, the CBT shall also
document that the individual is at risk of NF placement in the absence of home
and community-based services by finding that at least one of the following
conditions exists:
a. The individual has been
cared for in the home prior to the screening and evidence is available
demonstrating a deterioration in the individual's health care condition, a
significant change in condition, or a change in available supports. Examples of
such evidence may include (i) recent hospitalizations, (ii) attending physician
documentation, or (iii) reported findings from medical or social service
agencies.
b. There has been no
significant change in condition or available support but evidence is available
that demonstrates the individual's functional, medical, or nursing needs are
not being met. Examples of such evidence may include (i) recent
hospitalizations, (ii) attending physician documentation, or (iii) reported
findings from medical or social service agencies.
7. If the individual selects NF placement,
the CBT shall follow the Level I identification and Level II evaluation process
as outlined in Part III (12VAC30-130-140 et seq.) of 12VAC30-130.
8. If the CBT determines that the individual
does not meet the criteria set out in
12VAC30-60-303,
the CBT shall notify the individual or the individual's representative, as may
be appropriate, in writing that LTSS are being denied for the individual. The
denial notice shall include the individual's right to appeal consistent with
DMAS client appeals regulations (12VAC30-110).
9. For those screenings conducted in
accordance with clause iv of
12VAC30-60-302 B 1, the DMAS
designee shall follow the process outlined in this subsection.
B. Community screenings for children.
1. Medical or nursing and
functional eligibility for Medicaid-funded LTSS shall be determined by the DMAS
designee after completion of a screening of the child's needs and available
supports. The DMAS designee shall consider all the supports available for that
child in the community (i.e., the immediate family, other community resources
), and other services in the continuum of LTSS. The screening shall be
documented on the designated DMAS forms identified in
12VAC30-60-306.
2. Upon receipt of a screening request, the
DMAS designee shall schedule an appointment to complete the requested
screening. Community settings where screenings may occur include the child's
residence, other residences, children's residential facilities, or other
settings with the exception of acute care hospitals, rehabilitation units of
acute care hospitals, and rehabilitation hospitals.
3. The DMAS designee shall:
a. Determine the appropriate degree of
participation and assistance given by other persons to the individual during
the screening in recognition of the individual's preferences to the extent
feasible.
b. Observe the child's
ability to perform appropriate ADLs according to
12VAC30-60-303
and consider the parent's, legal guardian's, or emancipated child's
communications or responses to questions;
c. Observe, assess, and report the child's
medical or nursing and functional condition. This information shall be used to
ensure accurate and comprehensive evaluation of the child's need for
modification of treatment or additional medical procedures to prevent
destabilization even when the child has demonstrated an inability to
self-observe or evaluate the need to contact skilled medical
professionals;
d. Identify the
medical or nursing and the functional needs of the child; and
e. Consider services and settings that may be
needed by the child in order for the child to safely perform ADLs in the
community.
4. Upon
completion of the screening and in consideration of the communication from the
child or his representative, if appropriate, and observations obtained during
the screening, the DMAS designee shall determine whether the child meets the
criteria set out in
12VAC30-60-303.
If the child meets the criteria for Medicaid-funded LTSS, the DMAS designee
shall inform the child and his representative, if appropriate, of this
determination in writing and provide choice of the feasible alternatives, such
as PACE or home and community-based waiver services, to NF placement.
5. If waiver services are declined, the
reason for declining shall be recorded on the DMAS-97, Individual Choice -
Institutional Care or Waiver Services Form. The DMAS designee shall have this
document signed by either the emancipated child or his representative. In
addition to the electronic document, a paper copy of the DMAS-97 form with the
child's or his representative's signature shall be retained in the child's
record by the screening entity.
6.
If the child meets criteria and selects home and community-based services, the
DMAS designee shall also document that the individual is at risk of NF
placement in the absence of home and community-based services by finding that
at least one of the following conditions exists:
a. The child has been cared for in the home
prior to the screening and evidence is available demonstrating a deterioration
in the child's health care condition, a significant change in condition, or a
change in available supports. Examples of such evidence may include (i) recent
hospitalizations, (ii) attending physician documentation, or (iii) reported
findings from medical or social service agencies.
b. There has been no significant change in
condition or available support but evidence is available that demonstrates the
child's functional, medical, or nursing needs are not being met. Examples of
such evidence may include (i) recent hospitalizations, (ii) attending physician
documentation, or (iii) reported findings from medical or social service
agencies.
7. If the
parent, legal guardian, entity having legal custody of the child, or
emancipated child selects NF placement, the DMAS designee shall follow the
Level I identification and Level II evaluation process as set out in Part III
(12VAC30-130-140 et seq.) of 12VAC30-130.
8. If the DMAS designee determines that the
child does not meet the criteria to receive Medicaid-funded LTSS as set out in
12VAC30-60-303,
the DMAS designee shall notify the parent, legal guardian, entity having legal
custody of the child, or the emancipated child and representative, as may be
appropriate, in writing that Medicaid-funded LTSS are being denied for the
child. The denial notice shall include the child's right to appeal consistent
with DMAS client appeals regulations (12VAC30-110).
C. Screenings for adults and children in hospitals. For the purpose of this subsection, the term "individual" shall mean either an adult or a child.
1. Medical or
nursing and functional eligibility for Medicaid-funded LTSS shall be determined
by the hospital screening team after completion of a screening of the
individual's medical or nursing and functional needs and available supports.
The hospital screening team shall consider all the supports available for that
individual in the community (i.e., the immediate family, other relatives, other
community resources), and other services in the continuum of LTSS.
2. Screenings shall be completed in the
hospital prior to discharge. The individual shall be permitted to have another
person present at the time of the screening. Except when a court has issued an
order for a screening, the individual shall also be afforded the right to
refuse to participate. The hospital screening team shall determine the
appropriate degree of participation and assistance given by other persons to
the individual during the screening and accommodate the individual's
preferences to the extent feasible.
3. The hospital screening team shall:
a. Observe the individual's ability to
perform appropriate ADLs according to
12VAC30-60-303,
excluding all institutionally induced dependencies, and consider the
individual's communication or responses to questions or his representative's
communication or responses;
b.
Observe, assess, and report the individual's medical or nursing and functional
condition. This information shall be used to ensure accurate and comprehensive
evaluation of the individual's need for modification of treatment or additional
medical procedures to prevent destabilization even when the individual has
demonstrated an inability to self-observe or evaluate the need to contact
skilled medical professionals;
c.
Identify the medical, nursing, and functional needs of the individual;
and
d. Consider services and
settings that may be needed by the individual in order for the individual to
safely perform ADLs.
4.
Upon completion of the screening and in consideration of the communication from
the individual or his representative, if appropriate, and observations obtained
during the screening, the hospital screening team shall determine whether the
individual meets the criteria set out in
12VAC30-60-303.
If the individual meets the criteria for Medicaid-funded LTSS, the hospital
screening team shall inform the individual or his representative, if
appropriate, of this determination in writing and provide choice of the
feasible alternatives, such as PACE or home and community-based waiver
services, to placement in a NF.
5.
If waiver services or PACE, where available, are declined, the reason for
declining shall be recorded on the DMAS-97, Individual Choice - Institutional
Care or Waiver Services Form. The hospital screening team shall have this
document signed by either the individual or his representative, if appropriate.
In addition to the electronic document, a paper copy of the DMAS-97 form with
the individual's or his representative's signature shall be retained in the
individual's record.
6. If the
individual meets criteria and selects home and community-based services, the
hospital screening team shall also document that the individual is at risk of
NF placement in the absence of home and community-based services by finding
that at least one of the following conditions exists:
a. Prior to the inpatient admission, the
individual was cared for in the home and evidence is available demonstrating a
deterioration in the individual's health care condition, a significant change
in condition, or a change in available supports. Examples of such evidence may
include (i) recent hospitalizations, (ii) attending physician documentation, or
(iii) reported findings from medical or social service agencies.
b. There has been no significant change in
condition or available support but evidence is available that demonstrates the
individual's functional, medical, or nursing needs are not being met. Examples
of such evidence may include (i) recent hospitalizations, (ii) attending
physician documentation, or (iii) reported findings from medical or social
service agencies.
7. If
the individual selects NF placement, the hospital screening team shall follow
the Level I identification and Level II evaluation process as outlined in Part
III (12VAC30-130-140 et seq.) of 12VAC30-130.
8. If the hospital screening team determines
that the individual does not meet the criteria set out in
12VAC30-60-303,
the hospital screening team shall notify the individual or the individual's
representative, as may be appropriate, in writing that LTSS are being denied
for the individual. The denial notice shall include the individual's right to
appeal consistent with DMAS client appeals regulations (12VAC30-110).
Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Disclaimer: These regulations may not be the most recent version. Virginia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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