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 for Medicaid-funded long-term services and supports

Current through Register Vol. 40, No. 24, July 15, 2024
A. Community
				screenings for adults.
1. Medical or nursing
				and functional eligibility for Medicaid-funded LTSS shall be determined by the
				CBT after completion of a 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 screening shall
				be documented on the DMAS-designated forms identified in
				12VAC30-60-306.
2. 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 screening be performed in an alternate location within the same
				jurisdiction. 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 a 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 screening and accommodate the individual's preferences to the extent
				feasible.
3. 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 his
				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.
4. Upon completion
				of the screening and in consideration of the communication from the individual
				or his representative, if appropriate, and observations obtained during the
				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 his representative, if appropriate, of this determination in
				writing and provide choice of the feasible alternatives, such as PACE or home
				and community-based waiver services, to placement in a NF.
5. 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 his
				representative, if appropriate. In addition to the electronic document, a paper
				copy of the DMAS-97 form with the individual's or his representative's
				signature shall be retained in the individual's record by the screening
				entity.
6. 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.
7. 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.
8. 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).
9. For those screenings conducted in
				accordance with clause iv of
				12VAC30-60-302 B 1, the DMAS
				designee shall follow the process outlined in this subsection.