Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 122 - COMMUNITY WAIVER SRVICES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES › Section 12VAC30-122-20 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this chapter shall
				  have the following meanings unless the context clearly indicates
				  otherwise:
"AAIDD" means the American Association on Intellectual and
				  Developmental Disabilities.
"Activities of daily living" or "ADLs" means personal care
				  tasks, for example, bathing, dressing, using a toilet, transferring, and eating
				  or feeding. An individual's degree of independence in performing these
				  activities is a part of determining appropriate level of care and service
				  needs.
"Agency-directed model" means a model of service delivery
				  where an agency is responsible for providing direct support staff, for
				  maintaining individuals' records, and for scheduling the dates and times of the
				  direct support staff's presence in an individual's home and in
				  community.
"Appeal" means the process used to challenge actions
				  regarding services, benefits, and reimbursement provided by Medicaid pursuant
				  to 12VAC30-110 and
				  12VAC30-20-500
				  through
				  12VAC30-20-560.
"Assistive technology" or "AT" means specialized medical
				  equipment and supplies, including those devices, controls, or appliances
				  specified in the individual support plan but not available under the State Plan
				  for Medical Assistance that (i) enable individuals to increase their abilities
				  to perform ADLs; (ii) enable individuals to perceive, control, or communicate
				  with their environment; (iii) actively participate in other waiver services
				  that are part of their plan for supports; or (iv) are necessary to the proper
				  functioning of the specialized equipment.
"Back-up plan" means provision for alternative arrangements
				  for the delivery of services that are critical to participant well-being in the
				  event that the provider responsible for furnishing the services fails or is
				  unable to deliver them.
"Barrier crime" means those crimes listed in §
									19.2-392.02
				  of the Code of Virginia and as they apply to §§
									32.1-162.9:1,
				  37.2-314,
				  37.2-416,
				  37.2-506,
				  37.2-607,
				  and
				  63.2-1719
				  of the Code of Virginia.
"Behavioral health authority" or "BHA" means the same as
				  defined in §
									37.2-100 of the Code
				  of Virginia.
"Benefits planning" means an individualized analysis and
				  consultation service that assists recipients of a DD waiver and social security
				  (SSI, SSDI, SSI/SSDI) to understand their personal benefits and explore their
				  options regarding working, how to begin employment, and the impact employment
				  will have on their state and federal benefits.
"BI" means the Building Independence Waiver as further
				  described in 12VAC30-122-240.
"Center-based crisis support services" means crisis support
				  services provided in a crisis therapeutic home.
"Centers for Medicare and Medicaid Services" or "CMS" means
				  the unit of the U.S. Department of Health and Human Services that administers
				  and funds the Medicare and Medicaid programs.
"Challenging behavior" means behaviors of such intensity,
				  frequency, and duration that the physical safety of the individual or others is
				  placed in serious jeopardy or the behavior limits access to the community.
				  Challenging behavior may include withdrawal, self-injury, injury to others,
				  aggression, or self-stimulation.
"CL" means the Community Living Waiver as described in
				  12VAC30-122-250.
"Community-based crisis support services" means crisis
				  support services provided to individuals in their homes and in community
				  settings.
"Community coaching" means a service designed for individuals
				  who require one-to-one support in a variety of community settings in order to
				  develop specific skills to address barriers that prevent that individual from
				  participating in community engagement services.
"Community engagement" means, for the purpose of building
				  relationships and natural supports, services that support and foster
				  individuals' abilities to acquire, retain, or improve skills necessary to build
				  positive social behavior, interpersonal competence, greater independence,
				  employability, and personal choice necessary to access typical activities and
				  benefits of community life equal to those available to the general population.
				  Community engagement services shall be provided in groups no larger than three
				  individuals with a minimum of one DSP.
"Community Guide" means direct assistance to promote
				  individuals' self-determination through brokering specific community resources
				  that lead to connection to and independent participation in integrated,
				  independent housing, or community activities so as to avoid isolation.
"Community services board" or "CSB" means the same as defined
				  in §
									37.2-100 of the Code
				  of Virginia.
"Companion" means a person who provides companion services
				  for compensation by DMAS.
"Companion services" means nonmedical care, support, and
				  socialization provided to an adult individual age 18 years and older in
				  accordance with a therapeutic goal in the individual support plan. Companion
				  services are not purely recreational in nature and shall not provide routine
				  support with ADLs.
"Consumer direction" means a model of service delivery for
				  which the individual or the individual's employer of record, as appropriate,
				  shall be responsible for hiring, training, supervising, and firing of the
				  person who provides the direct support or specific services covered by DMAS and
				  whose wages are paid by DMAS through its fiscal agent.
"Crisis support services" means intensive supports by trained
				  and, where applicable, licensed staff in crisis prevention, crisis
				  intervention, and crisis stabilization for an individual who is experiencing an
				  episodic behavioral or psychiatric event that has the potential to jeopardize
				  his current community living situation.
"Customized rate" means a reimbursement rate that may be
				  available to group home residential, sponsored residential, supported living
				  residential, group day, community coaching, and in-home support service
				  providers that exceeds the normal rate applicable to the individual receiving
				  these specific services.
"DARS" means the Department for Aging and Rehabilitative
				  Services.
"DBHDS" means the Department of Behavioral Health and
				  Developmental Services.
"DBHDS staff" means persons employed by or contracted with
				  DBHDS.
"Developmental Disability Waivers" or "DD Waivers" means the
				  waiver program established in this chapter and consisting of the FIS, CL, and
				  BI waivers.
"Developmental disability" means the same as defined in
				  §
									37.2-100 of the Code
				  of Virginia.
"Direct support professional," "direct care staff," or "DSP"
				  means staff members identified by the provider as having the primary role of
				  assisting an individual on a day-to-day basis with routine personal care needs,
				  social support, and physical assistance in a wide range of daily living
				  activities so that the individual can lead a self-directed life in his own
				  community. This term shall exclude consumer-directed staff and services
				  facilitation providers.
"DMAS" means the Department of Medical Assistance
				  Services.
"DMAS staff" means persons employed by or contracted with
				  DMAS.
"Electronic home-based support" or "EHBS" means goods and
				  services based on current technology, such as Smart
				  Home©, and includes purchasing electronic
				  devices, software, services, and supplies that allow individuals to use
				  technology in their residences to achieve greater independence and
				  self-determination and reduce the need for staff intervention but that are not
				  otherwise covered through other benefits in the DD Waivers or through the State
				  Plan for Medical Assistance.
"Electronic visit verification" or "EVV" means a telephone,
				  computer-based system, or other electronic technology used in real time to
				  document, verify, and report the delivery of certain specified information
				  about the provision of in-home or other community location, personal care,
				  respite, companion services, and home health services. The EVV system shall
				  report the precise time that services begin and end.
"Employer of record" or "EOR" means the person who performs
				  the functions of the employer in the consumer-directed model of service
				  delivery and may be the individual enrolled in the waiver, a family member, an
				  unpaid caregiver, or another designated person.
"Employment and community transportation" means a service
				  offered to enable individuals to gain access to an individual's place of
				  employment or volunteer activity, other community services or events,
				  activities and resources, homes of family or friends, civic organizations or
				  social clubs, public meetings or other civic activities, and spiritual
				  activities or events as specified by the support plan and when no other means
				  of access is available.
"Employment services organization" means providers of
				  employment services with DARS. DARS verifies that these providers meet criteria
				  to be providers through a DARS-recognized accrediting body.
"Enroll" with respect to an individual means (i) the local
				  department of social services has determined the individual's financial
				  eligibility for Medicaid as set out in 12VAC30-122-60; (ii) the individual has
				  been determined by the support coordinator to be at risk of
				  institutionalization and to meet the functional eligibility requirements in the
				  Virginia Intellectual Developmental Disabilities Eligibility Survey form, which
				  is referenced in 12VAC30-122-70, for the waiver; (iii) the Department of
				  Behavioral Health and Developmental Services has verified the availability of a
				  waiver slot for the individual; and (iv) the individual has agreed to accept
				  the waiver slot.
"Environmental modifications" or "EM" means physical
				  adaptations to the individual's home or primary vehicle that are necessary to
				  ensure the individual's health and welfare or to enable functioning with
				  greater independence.
"EPSDT" means the Early and Periodic Screening, Diagnosis and
				  Treatment program administered by DMAS for children younger than 21 years of
				  age according to federal guidelines that prescribe preventive and treatment
				  services for Medicaid eligible children and as defined in
				  12VAC30-50-130.
"Face-to-face contact" means an in-person meeting between the
				  support coordinator and the individual and family/caregiver, as appropriate,
				  for the purpose of assessing the individual's status and determining
				  satisfaction with services, including the need for additional services and
				  supports.
"Family" means, for the purpose of receiving individual and
				  family/caregiver training services, the unpaid people who live with or provide
				  care to an individual served by the waiver and may include a parent, a legal
				  guardian, a spouse, children, relatives, a foster family, or in-laws but shall
				  not include persons who are compensated to care for the individual.
"FIS" means the Family and Individual Support Waiver as
				  further described in 12VAC30-122-260.
"General supports" means staff presence to ensure that
				  appropriate action is taken in an emergency or an unanticipated event and
				  includes (i) awake staff during nighttime hours; (ii) routine bed checks; (iii)
				  oversight of unstructured activities; or (iv) asleep staff at night on premises
				  for security or safety reasons.
"Group day services" means services for the individual to
				  acquire, retain, or improve skills of self-help, socialization, community
				  integration, employability, and adaptation via opportunities for peer
				  interactions, community integration, and enhancement of social networks.
"Group home residential services" means skill-building,
				  routine supports, general supports, and safety supports that are provided in a
				  residence licensed by DBHDS or an adult foster care home approved by the local
				  department of social services that enable the individual to acquire, retain, or
				  improve skills necessary to lead a self-directed life in his own
				  community.
"Home and community-based waiver services," "HCBS," or
				  "waiver services" means the range of community services approved by CMS
				  pursuant to § 1915(c) of the Social Security Act to be offered to persons
				  as an alternative to institutionalization.
"ICF/IID" means a facility or distinct part of a facility
				  that (i) is licensed by DBHDS; (ii) meets the federal certification regulations
				  for an intermediate care facility for individuals with intellectual
				  disabilities and individuals with related conditions; (iii) addresses the total
				  needs of the individuals, which include physical, intellectual, social,
				  emotional, and habilitation, and (iv) provides active treatment as defined in
				  42 CFR 483.440.
"IDEA" means the Individuals with Disabilities Education Act
				  (
				  20 USC §
										1400 et seq.).
"Immediate family member" means spouses, parents (as "parent"
				  is defined in this section), children (biological, adoptive, foster, step, )
				  and siblings of the individual in the waiver.
"Independent living" means an individual living on his own
				  with sufficient opportunities to direct his life and make informed choices,
				  including the freedom to pursue activities fitting his capabilities and
				  interests while maximizing full participation in community life.
"Individual" means the Commonwealth's citizen, including a
				  child, who meets the income and resource standards in order to be eligible for
				  Medicaid-covered services, has a diagnosis of developmental disability, and is
				  eligible for the DD Waivers. The individual may be a person on the DD Waiver
				  waiting list or an enrolled person who is receiving these waiver
				  services.
"Individual support plan" or "ISP" means a comprehensive,
				  person-centered plan that sets out the supports and actions to be taken during
				  the year by each provider, as detailed in each provider's plan for supports to
				  achieve desired outcomes, and goals. The individual support plan shall be
				  developed collaboratively by the individual, the individual's family/caregiver,
				  as appropriate, providers, the support coordinator, and other interested
				  parties chosen by the individual and shall contain the DMAS-approved ISP
				  components as set forth in 12VAC30-122-190.
"Individual supported employment" means services that consist
				  of ongoing, one-on-one supports provided by a job coach that enable the
				  individual to be employed in an integrated work setting and may include
				  assisting the individual to locate a job or develop a job on behalf of the
				  individual, as well as activities needed to sustain paid work by the
				  individual.
"Individual's responses to services" means the individual's
				  behaviors in and responses to the services. In the case of an individual who
				  does not communicate through spoken language, this shall mean the individual's
				  condition and observable responses.
"In-home support services" means residential services that
				  take place primarily in the individual's home, family home, or community
				  settings that typically supplement the primary care provided to himself or by
				  family or another unpaid caregiver and are designed to enable the individual to
				  lead a self-directed life in the community while ensuring his health, safety,
				  and welfare.
"Instrumental activities of daily living" or "IADLs" means
				  skills that are needed to successfully live independently such as meal
				  preparation, shopping, housekeeping, laundry, and money management and do not
				  include ADLs.
"Job coach" means the person who instructs individuals with
				  disabilities utilizing structured intervention techniques to help the
				  individual learn to perform job tasks to the employer's specifications and to
				  learn the interpersonal skills necessary to be accepted as a worker at the job
				  site and in related community contacts.
"LEIE" means List of Excluded Individuals and Entities. For
				  the purpose of the use of LEIE, the use of the word "individual" shall not
				  refer to the enrolled waiver individual.
"Levels of support" means the level (1-7) that is assigned to
				  an individual based on the SIS® score, the
				  results of the Virginia Supplemental Questions, and, as needed, a supporting
				  document review verification process.
"Licensed practical nurse" or "LPN" means a person who is
				  licensed or holds multistate licensure privilege pursuant to Chapter 30 (§
									54.1-3000 et seq.) of
				  Title 54.1 of the Code of Virginia to practice practical nursing as defined in
				  §
									54.1-3000 of the Code
				  of Virginia.
"LMHP" means a licensed mental health professional as defined
				  in
				  12VAC30-50-130.
"LMHP-resident" means the same as defined in
				  12VAC30-50-130.
"LMHP-RP" means the same as defined in
				  12VAC30-50-130.
"LMHP-supervisee" means the same as defined in
				  12VAC30-50-130.
"Medically necessary" means an item or service provided for
				  the diagnosis or treatment of an individual's condition consistent with
				  community standards of medical practice and needed to maintain an individual in
				  the community instead of placement in an institution.
"Own home" means an individual residence that meets the legal
				  definition of a residential dwelling that can be owned or leased by an
				  individual.
"Parent" means a person who is biologically or naturally
				  related, a foster parent, step-parent, or an adoptive parent to the individual
				  enrolled in the waiver.
"Participating provider" means an entity that meets the
				  standards and requirements set forth by DMAS and has a current, signed provider
				  participation agreement with DMAS.
"Peer mentor supports" means information, resources,
				  guidance, and support from an experienced, trained peer mentor to an individual
				  who is a waiver recipient.
"Person-centered planning" means a fundamental process that
				  focuses on what is important to and for an individual and the needs and
				  preferences of the individual to create an individual support plan.
"Personal assistance service" means direct support or
				  supervision with (i) ADLs, (ii) IADLs, (iii) access to the community, (iv)
				  monitoring the self-administration of medication or other medical needs, and
				  (v) monitoring health status and physical condition. Personal assistance
				  services may occur in the home, community, work site, or postsecondary
				  school.
"Personal assistant" means a person who provides personal
				  assistance services employed either by a provider agency or under consumer
				  direction.
"Personal emergency response system" or "PERS" means an
				  electronic device and monitoring service, and also may include medication
				  monitoring units, that enable individuals to secure help in an
				  emergency.
"Personal profile" means a point-in-time synopsis of what an
				  individual enrolled in the waiver wants to maintain, change, improve in his
				  life, or goals and outcomes to achieve, and shall be completed by the
				  individual and another person, such as his support coordinator or
				  family/caregiver, chosen by the individual to help him plan before the annual
				  planning meeting where it is discussed and then finalized to inform the
				  individual supports plan process.
"Plan for supports" means each provider's plan for supporting
				  the individual enrolled in the waiver in achieving the individual's desired
				  outcomes and facilitating the individual's health and safety. The provider plan
				  for supports is one component of the individual support plan.
"Positive behavior support" means a set of research-based
				  strategies used to increase quality of life and decrease challenging behavior
				  by teaching new skills and making changes in a person's environment.
"Primary caregiver" means the primary person who consistently
				  assumes the role of providing direct care and support without compensation for
				  such care to the individual enrolled in the waiver to enable the individual to
				  live a self-directed life in the community.
"Private duty nursing services" means individual and
				  continuous nursing care for individuals who have a serious medical condition or
				  complex health care needs, or both, and that has been certified by a physician
				  as medically necessary to enable the individual to remain in a community
				  setting rather than in a hospital, nursing facility, or ICF/IID. This service
				  may be provided concurrently with other services.
"Progress notes" means individual-specific written
				  documentation that (i) contains unique differences specific to the individual's
				  circumstances and the supports provided, and the individual's responses to such
				  supports; (ii) is signed and dated by the person who rendered the supports; and
				  (iii) is signed and dated on the day the described supports were provided.
				  Documentation that occurs after the date supports were provided shall be dated
				  for the date the entry is recorded and the date of supports delivery shall be
				  noted in the body of the note.
"Qualified developmental disabilities professional" or "QDDP"
				  means a professional who (i) possesses at least one year of documented
				  experience working directly with individuals who have developmental
				  disabilities; (ii) is one of the following: a doctor of medicine or osteopathy,
				  a registered nurse, a provider holding at least a bachelor's degree in a human
				  service field including sociology, social work, special education,
				  rehabilitation engineering, counseling, or psychology; and (iii) possesses the
				  required Virginia or national license, registration, or certification in
				  accordance with his profession, if applicable.
"Quality management review" or "QMR" (i) means a process used
				  by DMAS to monitor provider compliance with DMAS participation standards and
				  policies and to ensure an individual's health, safety, and welfare and
				  individual satisfaction with services and (ii) includes a review of the
				  provision of services to ensure that services are being provided in accordance
				  with DMAS regulations, policies, and procedures.
"Registered nurse" or "RN" means a person who is licensed or
				  holds multistate licensure privilege pursuant to Chapter 30 (§
									54.1-3000 et seq.) of
				  Title 54.1 of the Code of Virginia to practice professional nursing.
"Respite services" means temporary substitute for care that
				  is normally provided by the unpaid primary caregiverand shall be provided on a
				  short-term basis due to the absence of or need for routine or periodic relief
				  of the primary caregiver or other unpaid caregiver.
"Routine supports" means supports that assist the individual
				  with ADLs and IADLs, if appropriate.
"Safety supports" means specialized assistance that is
				  required to ensure an individual's health and safety.
"Service authorization" means the process to approve specific
				  services for an enrolled Medicaid individual by a DMAS service authorization
				  designee prior to service delivery and reimbursement in order to validate that
				  the service requested is medically necessary and meets DMAS requirements for
				  reimbursement. Service authorization does not guarantee payment for the
				  service.
"Services facilitation" means a service that assists the
				  individual or EOR, as appropriate, in arranging for, directing, and managing
				  services provided through the consumer-directed model of service
				  delivery.
"Services facilitator" means (i) a DMAS-enrolled provider,
				  (ii) a DMAS-designated entity, or (iii) one who is employed by or contracts
				  with a DMAS-enrolled services facilitator that is responsible for supporting
				  the individual or EOR, as appropriate, by ensuring the development and
				  monitoring of the plan for supports for consumer-directed services, providing
				  employee management training, and completing ongoing review activities as
				  required. "Services facilitator" shall be deemed to mean the same thing as
				  "consumer-directed services facilitator."
"Shared living" means an arrangement in which a roommate
				  resides in the same household as the individual receiving waiver services and
				  provides an agreed-upon, limited amount of supports in exchange for which a
				  portion of the total cost of rent, food, and utilities that can be reasonably
				  attributed to the roommate is reimbursed to the individual.
"Skill building" means those supports that help the
				  individual gain new skills and abilities and was previously called
				  training.
"Skilled nursing services" means short-term nursing services
				  (i) ordered by a physician and listed in the plan for supports that are not
				  otherwise available under the State Plan for Medical Assistance, (ii) provided
				  within the scope of §
									54.1-3000 et seq. of
				  the Code of Virginia and the Drug Control Act (§
									54.1-3400 et seq. of the
				  Code of Virginia), and (iii) provided by a registered nurse or by a licensed
				  practical nurse under the supervision of a registered nurse who is licensed to
				  practice in the state or who holds a multistate licensure privilege. Skilled
				  nursing services are to be used to train and provide consultation, using nurse
				  delegation as appropriate, and oversight of direct staff consistent with the
				  Department of Health Professions requirements for delegation of tasks.
"Slot" means an opening or vacancy in waiver services.
"SSI" means social security income provided by the U.S.
				  Social Security Administration.
"Sponsored residential services" means residential services
				  that consist of skill-building, routine supports, general supports, and safety
				  supports provided in the homes of families or persons (sponsors) who provide
				  supports for no more than two individuals under the supervision of a
				  DBHDS-licensed provider that enable the individuals to acquire, retain, or
				  improve the self-help, socialization, and adaptive skills necessary to live a
				  self-directed life in the community.
"State Plan for Medical Assistance" or "Plan" means the
				  Commonwealth's legal document approved by CMS identifying the covered groups,
				  covered services and their limitations, and provider reimbursement
				  methodologies as provided for under Title XIX of the Social Security
				  Act.
"Support coordination/case management" means assessing and
				  planning of services; linking the individual to services and supports
				  identified in the individual support plan; assisting the individual directly
				  for the purpose of locating, developing, or obtaining needed services and
				  resources; coordinating services and service planning with other agencies and
				  providers involved with the individual; enhancing community integration; making
				  collateral contacts to promote the implementation of the individual support
				  plan and community integration; monitoring the individual to assess ongoing
				  progress and ensuring that authorized services are delivered; and educating and
				  counseling the individual to guide him to develop supportive relationships that
				  promote the individual support plan.
"Support coordinator" means the person who provides support
				  coordination services to an individual in accordance with
				  12VAC30-50-440
				  and
				  12VAC30-50-490.
				  Formerly, this was referred to as case manager and may be either an employee of
				  a CSB or of a private entity contracted with the local CSB.
"Supported living residential service " means a service
				  taking place in a residential setting operated by a DBHDS-licensed provider of
				  supervised living residential service or supportive in-home service that
				  consists of skill-building, routine supports, general supports, and safety
				  supports that enable the individual to acquire, retain, or improve self-help,
				  socialization, and adaptive skills necessary to live a self-directed life in
				  home and community settings.
"Supporting documentation" means any written or electronic
				  materials used to record and verify the individual's support needs, services
				  provided, and contacts made on behalf of the individual and may include, for
				  example, the personal profile, individual support plan, providers' plans for
				  supports, progress notes, reports, medical orders, contact logs, attendance
				  logs, and assessments.
"Supports" means paid and nonpaid assistance that promotes
				  the accomplishment of an individual's desired outcomes. There shall be four
				  types of supports: (i) routine supports that assist the individual in ADLs and
				  IADLs, if appropriate; (ii) skill building supports to help the individual gain
				  new abilities; (iii) safety supports that are required to ensure the
				  individual's health and safety; and (iv) general supports that provide general
				  oversight.
"Supports Intensity Scale®" or
				  "SIS®" means an assessment tool and form that is
				  published by the American Association on Intellectual and Developmental
				  Disabilities and administered through a thorough interview process that
				  measures and documents an individual's practical support requirements in
				  personal, school-related or work-related, social, behavioral, and medical areas
				  to suggest the types and intensity levels of the supports required by that
				  individual to live a self-directed life in the community and to inform the
				  discussion in the person-centered planning process.
"Therapeutic consultation" means professional consultation
				  provided by members of psychology, social work, rehabilitation engineering,
				  behavioral analysis, speech therapy, occupational therapy, psychiatry,
				  psychiatric clinical nursing, therapeutic recreation, physical therapy, or
				  behavior consultation disciplines that are designed to assist individuals,
				  parents, family members, and any other providers of support services with
				  implementing the individual support plan.
"Tiers of reimbursement" means four different rates of
				  provider reimbursement associated with certain DD waiver services, which are
				  tied to an individual's level of support need as determined by the Supports
				  Intensity Scale®.
"Transition services" means the same as defined in
				  12VAC30-120-2010.
"VDSS" means the Virginia Department of Social
				  Services.
"Virginia Individual Developmental Disabilities Eligibility
				  Survey" or "VIDES" means the required level of care tool for demonstrating
				  functional eligibility for the DD waivers. There are three types: adult, child,
				  and infant.
"Workplace assistance service" means supports provided to an
				  individual who has completed job development and completed or nearly completed
				  job placement training but requires more than the typical job coach services,
				  as in 12VAC30-122-400, to maintain stabilization in his employment.
Statutory Authority: §
											32.1-325
					 of the Code of Virginia;
					 42 USC §
												1396 et
					 seq.