Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part IX - Commonwealth Coordinated Care Plus Waiver › Section 12VAC30-120-930 - General requirements for home and community-based participating providers

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  following agency-directed services shall be provided through an agency that is
				  either (i) licensed by VDH, (ii) certified by VDH under provisions of Title
				  XVIII or Title XIX of the Social Security Act, or (iii) accredited either by
				  the Joint Commission on Accreditation of Health Care Organizations (JCAHO) or
				  by the Community Health Accreditation Program (CHAP) established by the
				  National League of Nursing for Medicaid participation: personal care, respite
				  care, PDN, skilled respite care, and congregate PDN. The provider shall make
				  available verification of its license, certification, or accreditation upon
				  request.
B. Requests for
				  participation shall be screened by DMAS or the designated DMAS contractor to
				  determine whether the provider applicant meets the requirements for
				  participation, as set forth in the provider agreement, and demonstrates the
				  abilities to perform, at a minimum, the following activities:
1. Screen all new and existing employees and
				  contractors to determine whether any are excluded from eligibility for payment
				  from federal health care programs, including Medicaid (i.e., via the United
				  States Department of Health and Human Services Office of Inspector General List
				  of Excluded Individuals or Entities (LEIE) website). Immediately report in
				  writing to DMAS any exclusion information discovered to: DMAS, ATTN: Program
				  Integrity/Exclusions, 600 East Broad Street, Suite 1300, Richmond, VA 23219, or
				  email to providerexclusions@dmas.virginia.gov;
2. Immediately notify DMAS in writing of any
				  change in the information that the provider previously submitted to
				  DMAS;
3. Ensure freedom of choice
				  to individuals in seeking services from any institution, pharmacy,
				  practitioner, or other provider qualified and enrolled in Medicaid at the time
				  of delivery to perform the service required, except for waiver individuals who
				  are subject to the DMAS Client Medical Management program as set out in Part
				  XIII of 12VAC30-130 or are enrolled in a Medicaid managed care
				  organization;
4. Ensure the
				  individual's freedom to refuse medical care, treatment, and services;
5. Accept referrals for services only when
				  staff is available to initiate and perform such services on an ongoing
				  basis;
6. Provide services and
				  supplies to individuals in full compliance with Title VI (42 USC §
												2000d
				  et seq.) of the Civil Rights Act of 1964 which prohibits discrimination on the
				  grounds of race, color, religion, or national origin; the Virginians with
				  Disabilities Act (§
											51.5-1 et seq. of the Code of
				  Virginia); § 504 of the Rehabilitation Act of 1973 (29 USC §
												794), which prohibits discrimination on the
				  basis of a disability; and the Americans with Disabilities Act of 1990
				  (42 USC §
												12101 et seq.), which provides comprehensive
				  civil rights protections to individuals with disabilities in the areas of
				  employment, public accommodations, state and local government services, and
				  telecommunications;
7. Provide
				  services and supplies to individuals of the same quality and in the same mode
				  of delivery as are provided to the general public;
8. Submit charges to DMAS, the MCO, or the
				  DMAS-designated service authorization contractor for the provision of services
				  and supplies to individuals in amounts not to exceed the provider's usual and
				  customary charges to the general public and accept as payment in full the
				  amount established by DMAS payment methodology beginning with the individual's
				  authorization date for the waiver services;
9. Use only DMAS-designated forms for service
				  documentation, except when otherwise permitted. The provider shall not alter
				  the DMAS forms in any manner without prior written approval from
				  DMAS;
10. Use DMAS-designated
				  billing forms for submission of charges;
11. Perform no type of direct marketing
				  activities to Medicaid individuals;
12. Maintain and retain business and
				  professional records sufficient to document fully and accurately the nature,
				  scope, and details of the services provided.
a. In all instances of forms required to be
				  in records, all documents shall have original notes, dates, and signatures.
				  Copied, re-dated, and photocopied forms, notes and signatures are prohibited.
				  Signatures shall not be dated prior to the last date of rendered services for
				  the appropriate form being used.
b.
				  In general, such records shall be retained for a period of at least six years
				  from the last date of service or as provided by applicable federal and state
				  laws, whichever period is longer. However, if an audit is initiated within the
				  required retention period, the records shall be retained until the audit is
				  completed and every exception resolved. Records of minors shall be kept for a
				  period of at least six years after such minor has reached 18 years of
				  age.
c. Policies regarding
				  retention of records shall apply even if the provider discontinues operation.
				  DMAS shall be notified in writing of the storage location and procedures for
				  obtaining records for review should the need arise. The location, agent, or
				  trustee shall be within the Commonwealth;
13. Furnish information on the request of and
				  in the form requested to DMAS, or its contractors, the Attorney General of
				  Virginia or their authorized representatives, federal personnel, and the state
				  Medicaid Fraud Control Unit. The Commonwealth's right of access to provider
				  agencies and records shall survive any termination of the provider
				  agreement;
14. Disclose, as
				  requested by DMAS, all financial, beneficial, ownership, equity, surety, or
				  other interests in any and all firms, corporations, partnerships, associations,
				  business enterprises, joint ventures, agencies, institutions, or other legal
				  entities providing any form of health care services to recipients of
				  Medicaid;
15. Pursuant to
				  42 CFR
				  431.300 et seq., §
											32.1-325.3 of the Code of
				  Virginia, and the Health Insurance Portability and Accountability Act (HIPAA),
				  safeguard and hold confidential all information associated with an applicant or
				  enrollee or individual that could disclose the identity of the applicant,
				  enrollee, or individual. Access to information concerning the applicant,
				  enrollee, or individual shall be restricted to persons or agency
				  representatives who are subject to the standards of confidentiality that are
				  consistent with that of the agency and any such access must be in accordance
				  with the provisions found in 42 CFR 431.306 and
				  12VAC30-20-90;
16. When ownership of the provider changes,
				  notify DMAS in writing at least 15 calendar days before the date of
				  change;
17. Pursuant to
				  §§
											63.2-100,
				  63.2-1509, and
				  63.2-1606 of the Code of
				  Virginia, if a participating provider or the provider's staff knows or suspects
				  that a home and community-based waiver services individual is being abused,
				  neglected, or exploited, the party having knowledge or suspicion of the abuse,
				  neglect, or exploitation shall report this immediately to the local department
				  of social services adult or child protective services department as applicable
				  or to the toll-free, 24-hour hotline as described on the local department of
				  social services' website. Employers shall ensure and document that their staff
				  is aware of this requirement;
a. The party
				  having knowledge or suspicion of abuse, neglect, or exploitation shall also
				  report this immediately to DMAS, or its authorized contractor separately as a
				  critical incident. The provider shall ensure that in such instances of
				  suspected or known abuse, neglect, and exploitation that DMAS, or its
				  authorized contractor are informed after notifying adult or child protective
				  services and will document the date and time of report.
b. If a participating provider or the
				  provider's staff knows or suspects that a waiver individual has incurred a
				  critical incident that does not include suspected or known abuse, neglect, or
				  exploitation, the party having knowledge or suspicion of the critical incident
				  shall report this immediately to DMAS or the DMAS-designated contractor.
				  Employers shall ensure and document that their staff is aware of this
				  requirement and maintain copies of all records of reported critical incidents
				  in the individual's file.
18. In addition to compliance with the
				  general conditions and requirements, adhere to the conditions of participation
				  outlined in the provider's participation agreements, in the applicable DMAS
				  provider manual, and in other DMAS laws, regulations, and policies. DMAS shall
				  conduct ongoing monitoring of compliance with provider participation standards
				  and DMAS policies. A provider's noncompliance with DMAS policies and procedures
				  may result in a retraction of Medicaid payment or termination of the provider
				  agreement, or both;
19. Meet
				  minimum qualifications of staff.
a. For
				  reasons of Medicaid individuals' safety and welfare, all employees shall have a
				  satisfactory work record, as evidenced by at least two references from prior
				  job experience, including no evidence of abuse, neglect, or exploitation of
				  incapacitated or older adults or children. In instances of employees who have
				  worked for only one employer, such employees shall be permitted to provide one
				  appropriate employment reference and one appropriate personal reference
				  including no evidence of abuse, neglect, or exploitation of incapacitated or
				  older adults or children.
b.
				  Pursuant to 42 CFR
				  441.302 and
				  42 CFR
				  441.352, within 30 calendar days of
				  employment, the staff or volunteer shall obtain an original criminal record
				  clearance with respect to convictions for offenses specified in §
												19.2-392.02 of the Code of
				  Virginia or an original criminal history record from the Central Criminal
				  Records Exchange.
(1) DMAS shall not reimburse
				  a provider for services provided by a staff member or volunteer who works in a
				  position that involves direct contact with a waiver individual until an
				  original criminal record clearance or original criminal history record has been
				  received. DMAS shall reimburse services provided by such staff member or
				  volunteer during only the first 30 calendar days of employment if the provider
				  can produce documented evidence that such person worked only under the direct
				  supervision of another staff member or volunteer for whom a background check
				  was completed in accordance with the requirements of this section. If an
				  original criminal record clearance or original criminal history record is not
				  received within the first 30 calendar days of employment, DMAS shall not
				  reimburse the provider for services provided by such employee on the 31st
				  calendar day through the date on which the provider receives an original
				  criminal record clearance or an original criminal history record.
(2) DMAS shall not reimburse a provider for
				  services provided by a staff member or volunteer who has been convicted of any
				  offense set forth in clause (i) of the definition of barrier crime in §
													19.2-392.02 of the Code of
				  Virginia unless all of the following conditions are met:
(i) the offense was punishable as a
				  misdemeanor;
(ii) the staff member
				  or volunteer has been convicted of only one such offense;
(iii) the offense did not involve abuse or
				  neglect; and
(iv) at least five
				  years have elapsed since the conviction.
c. The staff or volunteer shall provide the
				  hiring facility with a sworn statement or affirmation disclosing any criminal
				  convictions or any pending criminal charges, whether within or outside of the
				  Commonwealth.
d. Provider staff and
				  volunteers shall not be debarred, suspended, or otherwise excluded from
				  participating in federal health care programs, as listed on the federal List of
				  Excluded Individuals/Entities (LEIE) database at
https://oig.hhs.gov
.
e. Provider staff and volunteers who serve
				  waiver individuals who are minor children shall be screened through the VDSS
				  Child Protective Services (CPS) Central Registry. Provider staff and volunteers
				  shall not be reimbursed for services provided to the waiver individual
				  effective on the date and thereafter that the VDSS CPS Central Registry check
				  confirms the provider's staff person or volunteer has a finding.
20. Comply with the electronic
				  visit verification requirements set out in
				  12VAC30-60-65.
21. Providers shall comply with requirements
				  for person-centered planning and home and community-based settings as described
				  in 42 CFR
				  441.301. As part of the person-centered
				  planning process, providers shall discuss the available services to the
				  individual to meet the individual's needs and shall not perform services that
				  are not identified or agreed upon in the person-centered plan.