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 and nursing facilities 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 LTSS screenings for adults.
1. Medical or nursing
and functional eligibility for Medicaid-funded LTSS shall be determined by the
CBT after completion of an LTSS 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 LTSS
screening shall be documented on the DMAS-designated forms identified in
12VAC30-60-306.
2. Upon receipt of an LTSS screening request,
the CBT shall schedule an appointment to complete the requested LTSS screening.
LTSS 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 LTSS screening be performed
in an alternate location within the same jurisdiction. Community settings where
LTSS screenings may occur include the individual's residence, other residences,
residential facilities, or other settings with the exception of inpatients in
acute care hospitals, rehabilitation units of acute care hospitals, and
rehabilitation hospitals.
3. 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 an LTSS
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 LTSS
screening and accommodate the individual's preferences to the extent
feasible.
4. 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 the individual's
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.
5. Upon completion
of the LTSS screening and in consideration of the communication from the
individual or the individual's representative, if appropriate, and observations
obtained during the LTSS 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 the
individual's representative, if appropriate, of this determination in writing
and provide choice of the the setting and provider of LTSS, such as PACE or
Commonwealth Coordinated Care (CCC) Plus waiver services, as alternative
options to placement in an NF.
6.
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 the individual's representative, if appropriate. In addition
to the electronic document, a paper copy of the DMAS-97 form with the
individual's or the individual's representative's signature shall be retained
in the individual's record by the LTSS screening entity.
7. 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.
8. 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.
9. 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).
10. For those LTSS screenings conducted in
accordance with clause iv of
12VAC30-60-302 B 1, the CBT shall
follow the process outlined in this subsection.
B. Community LTSS screenings for children.
1. Medical or nursing and functional
eligibility for Medicaid-funded LTSS shall be determined by the DMAS community
screening designee after completion of an LTSS screening of the child's needs
and available supports. The DMAS community screening 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 LTSS screening shall be documented on the designated DMAS forms
identified in
12VAC30-60-306.
2. Upon receipt of an LTSS screening request,
the DMAS community screening designee shall schedule an appointment to complete
the requested LTSS screening. LTSS screenings shall be completed in the child's
residence unless the residence presents a safety risk for the child or the DMAS
community screening designee, or unless the child's representative requests
that the LTSS screening be performed in an alternate location within the same
jurisdiction. Community settings where LTSS 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 inpatients in acute care hospitals, and rehabilitation hospitals.
3. The child shall be permitted to have
another person present at the time of the LTSS screening. The DMAS community
screening designee shall determine the appropriate degree of participation and
assistance given by other persons to the child during the LTSS screening and
accommodate the individual's preferences to the extent feasible.
4. The DMAS community screening designee
shall:
a. Determine the appropriate degree of
participation and assistance given by other persons to the individual during
the LTSS 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.
5. Upon
completion of the LTSS screening and in consideration of the communication from
the child or the child's representative, if appropriate, and observations
obtained during the LTSS screening, the DMAS community screening 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 community screening designee
shall inform the child and the child's representative, if appropriate, of this
determination in writing and provide choice of the setting and provider of
LTSS, such as PACE or Commonwealth Coordinated Care Plus waiver services, as
alternative options to placement in an NF.
6. 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 community screening
designee shall have this document signed by either the emancipated child or the
child's representative. In addition to the electronic document, a paper copy of
the DMAS-97 form with the child's or the child's representative's signature
shall be retained in the child's record by the LTSS screening entity.
7. If the child meets criteria and selects
home and community-based services, the DMAS community screening 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 LTSS 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.
8. If the parent, legal guardian, entity
having legal custody of the child, or emancipated child selects NF placement,
the DMAS community screening 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.
9. If the DMAS
community screening designee determines that the child does not meet the
criteria to receive Medicaid-funded LTSS as set out in
12VAC30-60-303, the DMAS community
screening 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 LTSS screening team after completion of an LTSS screening of
the individual's medical or nursing and functional needs and available
supports. The hospital LTSS 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. The LTSS screening shall be documented on the
DMAS-designated forms identified in
12VAC30-60-306 and entered into
the eMLS system.
2. LTSS screenings
shall be completed in the hospital prior to discharge.
3. The individual shall be permitted to have
another person present at the time of the LTSS screening. Except when a court
has issued an order for an LTSS screening, the individual shall also be
afforded the right to refuse to participate. The hospital LTSS 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.
4. The hospital LTSS 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 the individual's 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.
5.
Upon completion of the LTSS screening and in consideration of the communication
from the individual or the individual's representative, if appropriate, and
observations obtained during the LTSS screening, the hospital LTSS 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 LTSS screening team
shall inform the individual or the individual's representative, if appropriate,
of this determination in writing and provide choice of the setting and provider
of LTSS, such as PACE or Commonwealth Coordinated Care (CCC) Plus waiver
services, as alternative options to placement in an NF.
6. 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 LTSS screening team shall have this document signed by either the
individual or the individual's representative, if appropriate. In addition to
the electronic document, a paper copy of the DMAS-97 form with the individual's
or the individual's representative's signature shall be retained in the
individual's record.
7. If the
individual meets criteria and selects home and community-based services, the
hospital LTSS 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.
8. If
the individual selects NF placement, the hospital LTSS 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.
9. If the hospital
LTSS screening team determines that the individual does not meet the criteria
set out in
12VAC30-60-303, the hospital LTSS
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).
D. LTSS screenings for individuals receiving skilled or rehabilitation nursing services in a setting not covered by Medicaid and after discharge from an acute care hospital.
1. Medical or nursing and functional
eligibility for Medicaid-funded LTSS shall be determined by the NF LTSS
screening team after completion of an LTSS screening of the individual's
medical or nursing and functional needs and available supports. The NF LTSS
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. The LTSS screening
shall be documented on the DMAS forms identified in 12VA30-60-306 and entered
into the eMLS system.
2. LTSS
screenings shall be completed prior to the enrollment or initiation of
LTSS.
3. The individual shall be
permitted to have another person present at the time of the LTSS screening.
Except when a court has issued an order for an LTSS screening, the individual
shall also be afforded the right to refuse to participate. The NF LTSS
screening team shall determine the appropriate degree of participation and
assistance given by other persons to the individual during the LTSS screening
and accommodate the individual's preferences to the extent feasible.
4. The nursing facility LTSS 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 the individual's 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.
5.
Upon completion of the LTSS screening and in consideration of the communication
from the individual or the individual's representative, if appropriate, and
observations obtained during the LTSS screening, the NF LTSS 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 NF LTSS screening team shall
inform the individual or the individual's representative, if appropriate, of
this determination in writing and provide choice of the setting and provider of
LTSS, such as PACE or Commonwealth Coordinated Care (CCC) Plus waiver services,
as alternative options to placement in an NF.
6. 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 NF
LTSS screening team shall have this document signed by either the individual or
the individual's representative, if appropriate. In addition to the electronic
document, a paper copy of the DMAS-97 form with the individual's or the
individual's representative's signature shall be retained in the individual's
record.
7. If the individual meets
criteria and selects home and community-based services, the NF LTSS 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 admission to the acute care hospital, 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.
8. If
the individual selects NF placement, the NF LTSS 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.
9. If the NF LTSS
screening team determines that the individual does not meet the criteria set
out in 12VAC30-60-303, the NF LTSS
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.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
