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 12VAC30-60-40 - Utilization control: Nursing facilities

Current through Register Vol. 40, No. 24, July 15, 2024
A. Long-term care of residents in nursing
				facilities will be provided in accordance with federal law using practices and
				procedures that are based on the resident's medical and social needs and
				requirements. All nursing facility services, including specialized care, shall
				be provided in accordance with guidelines found in the Virginia Medicaid
				Nursing Home Manual.
B. Nursing
				facilities must conduct initially and periodically a comprehensive, accurate,
				standardized, reproducible assessment of each resident's functional capacity.
				This assessment must be conducted no later than 14 days after the date of
				admission and promptly after a significant change in the resident's physical or
				mental condition. Each resident must be reviewed at least quarterly, and a
				complete assessment conducted at least annually.
C. The Department of Medical Assistance
				Services shall periodically conduct a validation survey of the assessments
				completed by nursing facilities to determine that services provided to the
				residents are medically necessary and that needed services are provided. The
				survey will be composed of a sample of Medicaid residents and will include
				review of both current and closed medical records.
D. Nursing facilities must submit to the
				Department of Medical Assistance Services resident assessment information at
				least every six months for utilization review. If an assessment completed by
				the nursing facility does not reflect accurately a resident's capability to
				perform activities of daily living and significant impairments in functional
				capacity, then reimbursement to nursing facilities may be adjusted during the
				next quarter's reimbursement review. Any individual who willfully and knowingly
				certifies (or causes another individual to certify) a material and false
				statement in a resident assessment is subject to civil money
				penalties.
E. In order for
				reimbursement to be made to the nursing facility for a recipient's care, the
				recipient must meet nursing facility criteria as described in
				12VAC30-60-300 (Nursing facility
				criteria). In order for the additional $10 per day reimbursement to be made to
				the nursing facility for a recipient requiring a specialized treatment bed, the
				recipient must meet criteria as described in
				12VAC30-60-350. Nursing facilities
				must obtain prior authorization for the reimbursement. DMAS shall provide the
				additional $10 per day reimbursement for recipients meeting criteria for no
				more than 246 days annually. Nursing facilities may receive the reimbursement
				for up to 82 days per new occurrence of a Stage IV ulcer. There must be at
				least 30 days between each reimbursement period. Limits are per recipient,
				regardless of the number of providers rendering services. Nursing facilities
				are not eligible to receive this reimbursement for recipients enrolled in the
				specialized care program.
In order for reimbursement to be made to the nursing facility
				  for a recipient requiring specialized care, the recipient must meet specialized
				  care criteria as described in
				  12VAC30-60-320 (Adult
				  ventilation/tracheostomy specialized care criteria) or
				  12VAC30-60-340 (Pediatric and
				  adolescent specialized care criteria). Reimbursement for specialized care must
				  be preauthorized by the Department of Medical Assistance Services. In addition,
				  reimbursement to nursing facilities for residents requiring specialized care
				  will only be made on a contractual basis. Further specialized care services
				  requirements are set forth below.
In each case for which payment for nursing facility services
				  is made under the State Plan, a physician must recommend at the time of
				  admission, or if later, the time at which the individual applies for medical
				  assistance under the State Plan, that the individual requires nursing facility
				  care.
F. For nursing
				facilities, a physician must approve a recommendation that an individual be
				admitted to a facility. The resident must be seen by a physician at least once
				every 30 days for the first 90 days after admission, and at least once every 60
				days thereafter. At the option of the physician, required visits after the
				initial visit may alternate between personal visits by the physician and visits
				by a physician assistant or nurse practitioner.
G. When the resident no longer meets nursing
				facility criteria or requires services that the nursing facility is unable to
				provide, then the resident must be discharged.
H. Specialized care services.
1. Providers must be nursing facilities
				certified by the Division of Licensure and Certification, State Department of
				Health, and must have a current signed participation agreement with the
				Department of Medical Assistance Services to provide nursing facility care.
				Providers must agree to provide care to at least four residents who meet the
				specialized care criteria for children/adolescents or adults.
2. Providers must be able to provide the
				following specialized services to Medicaid specialized care recipients:
a. Physician visits at least once weekly
				(after initial physician visit, subsequent visits may alternate between
				physician and physician assistant or nurse practitioner);
b. Skilled nursing services by a registered
				nurse available 24 hours a day;
c.
				Coordinated multidisciplinary team approach to meet the needs of the
				resident;
d. Infection
				control;
e. For residents under age
				21 who require two of three rehabilitative services (physical therapy,
				occupational therapy, or speech-language pathology services), therapy services
				must be provided at a minimum of 90 minutes each day, five days per
				week;
f. Ancillary services related
				to a plan of care;
g. Respiratory
				therapy services by a board-certified therapist (for ventilator patients, these
				services must be available 24 hours per day);
h. Psychology services by a licensed clinical
				psychologist, licensed clinical social worker, licensed professional counselor,
				or licensed clinical nurse specialist-psychiatric related to a plan of
				care;
i. Necessary durable medical
				equipment and supplies as required by the plan of care;
j. Nutritional elements as
				required;
k. A plan to assure that
				specialized care residents have the same opportunity to participate in
				integrated nursing facility activities as other residents;
l. Nonemergency transportation;
m. Discharge planning; and
n. Family or caregiver training.
3. Providers must coordinate with
				appropriate state and local agencies for educational and habilitative needs for
				Medicaid specialized care recipients who are under the age of 21.