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 12VAC30-60-50 - Utilization control: Intermediate care facilities for persons with intellectual and developmental disabilities and institutions for mental disease

Current through Register Vol. 40, No. 24, July 15, 2024
A. "Institution for
				mental disease" or "IMD" means the same as that term is defined in §
				1905(i) of the Social Security Act.
B. With respect to each Medicaid-eligible
				resident in an intermediate care facility for persons with intellectual and
				developmental disabilities (ICF/ID) or an IMD in Virginia, a written plan of
				care must be developed prior to admission to or authorization of benefits in
				such facility, and a regular program of independent professional review
				(including a medical evaluation) shall be completed periodically for such
				services. The purpose of the review is to determine: the adequacy of the
				services available to meet the resident's current health needs and promote the
				resident's maximum physical well being; the necessity and desirability of the
				resident's continued placement in the facility; and the feasibility of meeting
				the resident's health care needs through alternative institutional or
				noninstitutional services. Long-term care of residents in such facilities will
				be provided in accordance with federal law that is based on the resident's
				medical and social needs and requirements.
C. With respect to each ICF/ID or IMD,
				periodic onsite inspections of the care being provided to each person receiving
				medical assistance, by one or more independent professional review teams
				(composed of a physician or registered nurse and other appropriate health and
				social service personnel), shall be conducted. The review shall include, with
				respect to each recipient, a determination of the adequacy of the services
				available to meet the resident's current health needs and promote the
				resident's maximum physical well-being, the necessity and desirability of
				continued placement in the facility, and the feasibility of meeting the
				resident's health care needs through alternative institutional or
				noninstitutional services. Full reports shall be made to the state agency by
				the review team of the findings of each inspection, together with any
				recommendations.
D. In order for
				reimbursement to be made to a facility for persons with intellectual and
				developmental disabilities, the resident must meet criteria for placement in
				such facility as described in
				12VAC30-60-360 and the
				facility must provide active treatment for intellectual or developmental
				disabilities.
E. In each case for
				which payment for nursing facility services for persons with intellectual or
				developmental disabilities or institution for mental disease services is made
				under the State Plan:
1. A certificate of
				need shall be completed by an independent certification team according to the
				requirements of
				12VAC30-50-130
				D 5. Recertification shall occur at least every 60 calendar days by a
				physician, or by a physician assistant or nurse practitioner acting within
				their scope of practice as defined by state law and under the supervision of a
				physician. The certification must be made at the time of admission or, if an
				individual applies for assistance while in the facility, before the Medicaid
				agency authorizes payment; and
2. A
				physician, or physician assistant or nurse practitioner acting within the scope
				of the practice as defined by state law and under the supervision of a
				physician, must recertify for each applicant at least every 60 calendar days
				that services are needed in a facility for persons with intellectual and
				developmental disabilities or an institution for mental disease.