Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part VI - Criteria for Intermediate Care for Mentally Retarded Persons › Section 12VAC30-130-460 - Directions for applying the criteria

Current through Register Vol. 40, No. 24, July 15, 2024
A. The references under the questions in the
				  following categories indicate those items which are on the Behavior Development
				  Survey (DMH 71 Revised 6/80). The absence of a reference indicates this
				  question is not addressed on the BDS form. Some categories on the Behavior
				  Development Survey are not incorporated since the information in that area of
				  the evaluation will be reflected elsewhere in the criteria or the condition is
				  not indicative of a functional deficit justifying a need for intermediate care.
PATIENT ASSESSMENT CRITERIA.
1. HEALTH STATUS -- To meet this
							 category:
a.
Two or more questions must be answered
							 with a 4, or Question No. 10 must be answered yes.
Rarely
Some- times
Often
Regu- larly
b.
How often is nursing care or nursing
							 supervision by a licensed nurse required for the following:
1
2
3
4
1.
Medication administration and/or
							 evaluation for effectiveness of a medication regime ((70) Receiving Medications
							 and History of Seizures pg.4)
1
2
3
4
2.
Direct services: i.e., care for lesions,
							 dressings, treatments, (other than shampoos, foot powder, etc.)
1
2
3
4
3.
Seizures control ((68) History of seizures
							 pg.4)
1
2
3
4
4.
Teaching diagnosed disease control and
							 care, including diabetes
1
2
3
4
5.
Management of care of diagnosed
							 circulatory or respiratory problems
1
2
3
4
6.
Motor disabilities which interfere with
							 all activities of daily living--bathing, dressing, mobility, toileting, etc.
1
2
3
4
7.
Observation for choking/aspiration while
							 eating, drinking
1
2
3
4
8.
Supervision for use of adaptive equipment,
							 i.e., special spoon, braces, etc. (physical aids pg.4)
1
2
3
4
9.
Observation for nutritional problems
							 (i.e., undernourishment, swallowing difficulties, obesity)
1
2
3
4
10.
Is age 55 or older, has a diagnosis of a
							 chronic disease and has been in an institution 20 years or more
yes
no
2. COMMUNICATION -- To meet this
							 category:
a.
Three or more questions must be answered
							 with a 3 or a 4.
No assis-tance
Prompt-ing/ Struc-turing
Super-vision
Some Direct Assis-tance
Total Assis-tance
b.
How often does this person:
1.
Indicate wants by pointing, vocal noises, or signs
							 ((62)(c) Preverbal Expression pg.2)
1
2
3
4
2.
Use simple words, phrases short sentences ((67)
							 Sentences pg.2)
1
2
3
4
3.
Ask for at least ten things using appropriate names
							 ((67) Vocabulary pg.1)
1
2
3
4
4.
Understand simple words, phrases or instructions
							 containing prepositions: i.e., on in behind ((27) Complex Instructions pg.3)
1
2
3
4
5.
Speak in an easily understood manner ((66) Speech
							 pg.1)
1
2
3
4
6.
Identify self, place of residence, and significant
							 other, ((47) Awareness of Others, pg.3)
1
2
3
4
3. TASK LEARNING SKILLS -- To meet this
							 category:
a.
Three or more questions must be answered
							 with a 3 or a 4.
Regu- larly
Often
Some-times
Rarely
b.
How often does this person:
1.
Pay attention to purposeful activities for 5 minutes
							 ((42)(2) Attention pg.3)
1
2
3
4
2.
Stay with a three-step task for more than 15 mintues
							 ((42) (5) Attention pg. 3)
1
2
3
4
3.
Tell time to the hour and understand time intervals
							 ((33) (b) Time pg. 3)
1
2
3
4
4.
Count more than 10 objects ((31) (5) Numbers pg.3)
1
2
3
4
5.
Do simple addition, subtraction ((31) (6)Numbers pg.3)
1
2
3
4
6.
Write or print ten words ((59) (3) Writing pg. 2)
1
2
3
4
7.
Discriminate shapes, sizes, or colors
1
2
3
4
8.
Name people or objects when describing pictures ((67)
							 (4) Vocabulary pg. 1)
1
2
3
4
9.
Discriminate between one, many, lot ((31) (2) Numbers
							 pg. 3)
1
2
3
4
4. PERSONAL/SELF CARE -- To meet this
							 category:
a.
Question No. 1 must be answered with a 4
							 or a 5, or
b.
Question No. 2 must be answered with a 4
							 or a 5, or
c.
Questions No. 3 and 4 must be answered
							 with a 4 or a 5
NOTE: The yes or no questions are for the
							 purpose of identification of needs to be included in the plan of care.
							 Questions answered yes or no are not part of the scale.
No Assis-tance
Prompt-ing/ Struc-turing
Super-vision
Some Direct Assis-tance
Total Assis-tance
d.
With what type of assistance can this
							 person currently:
1.
Perform toileting functions: i.e., maintain bladder
							 and bowel continence, clean self etc. ((31)(5) Toilet Training pg. 1)
1
2
3
4
5
(a) has toileting accidents more than twice a day
							 ((31)(2) Toilet Training pg. 1)
yes
no
(b) has toileting accidents at night
yes
no
(c) Flushes toilet, pulls up clothes ((36) Self Care
							 at Toilet pg. 2)
yes
no
2.
Perform eating/feeding functions: i.e., drinks liquids
							 and eats with spoon or fork, etc ((28)(3) Use of Table Utensils pg. 1)
1
2
3
4
5
(a) Feeds self with spoon neatly ((28)(3) Use of Table
							 Utensils)
yes
no
(b) Spilling ((3) (3) Drinking pg. 1)
yes
no
3.
Perform bathing functions (i.e., bathe, runs bath, dry
							 self, etc.) ((44)(5) Bathing pg. 2)
1
2
3
4
5
(a) Washes hands and face with soap ((39) (40) Washes
							 Hands and Face pg. 2)
yes
no
(b) Dries hands and face ((42) Washes Hands and Face
							 pg. 2)
yes
no
(c) Care for hair, nails, beard
yes
no
4.
Dress self completely i.e., including fastening,
							 putting on clothes, etc. ((5) (6) Dressing pg. 2)
1
2
3
4
5
(a) Dresses upper body, but needs help with fastening
yes
no
(b) Dresses self but needs assistance with pulling, or
yes
no
(c) Putting on most clothing, fastening, shoes ((50)
							 (3) Dressing (52) Shoes pg. 2)
yes
no
5. MOBILITY -- To meet this category:
a.
Any one question must be answered with a
							 4 or a 5.
NOTE: The yes or no questions are for the
							 purpose of identification of needs to be included in the plan of care.
							 Questions answered yes or no are not part of the scale.
No Assis-tance
Prompt-ing/ Struc-turing
Super-vision
Some Direct Assis-tance
Total Assis-tance
b.
With what type of assistance can this
							 person currently:
1.
Move (walking, wheeling) around environment ((59)
							 Ambulation pg. 1,(79) Physical Aids pg. 4)
1
2
3
4
5
(a) Walk with assistive device, person ((59)
							 Ambulation pg. 1, Physical Aids pg. 4)
yes
no
(b) Walk on level ground for 50 yards with or without
							 assistive device ((73, 74, 76) Physical Aids, pg. 4)
yes
no
(c) Transfer to/from a wheelchair ((75) Physical Aids
							 pg. 4)
yes
no
2.
Rise from lying down to sitting positions, sits
							 without support ((27) Body Balance pg. 1)
1
2
3
4
5
3.
Turn and position in bed, roll over
1
2
3
4
5
6. BEHAVIOR -- To meet this category:
a.
Any one question must be answered with a
							 3 or a 4.
Rarely
Some-times
Often
Regu- larly
b.
How often does this person:
1.
Engage in self-destructive behavior ((61)
							 Maladaptive Behavior pg. 4)
1
2
3
4
2.
Threaten or do physical violence to others
							 ((52) Maladaptive Behavior pg. 4)
1
2
3
4
3.
Throw things, damage property, have temper
							 outbursts ((53, 55) Maladaptive Behavior pg. 4)
1
2
3
4
4.
Respond to others in a socially
							 unacceptable manner (without undue anger, frustration or hostility) ((50)
							 Interactions with Others pg. 3)
1
2
3
4
7. COMMUNITY LIVING SKILLS -- To meet
							 this category:
a.
Any two of questions 2, 5, or 7 must be
							 answered with a 4 or a 5, or
b.
Three or more of questions 1 through 8
							 must be answered with a 4 or a 5.
No Assis-tance
Prompt-ing/ Struc-turing
Super-vision
Some Direct Assis-tance
Total Assis-tance
c.
With what type of assistance would this
							 person currently be able to:
1.
Prepare simple foods requiring no mixing
							 or cooking ((38) Food Preparation pg. 3)
1
2
3
4
5
2.
Take care of personal belongings, room
							 (excluding vacuuming, ironing, clothes washing/drying, wet mopping) ((43)
							 Personal Belongings pg. 3)
1
2
3
4
5
3.
Add coins of various demonima1 nations up
							 to one dollar ((57) Money Handling pg. 2)
1
2
3
4
5
4.
Use the telephone to call home, doctor,
							 fire, police
1
2
3
4
5
5.
Recognize survival signs/words: i.e.,
							 stop, go, traffic lights, police, men, women, restrooms, danger, etc. ((68)
							 Reading pg. 2)
1
2
3
4
5
6.
Refrain from exhibiting unacceptable
							 sexual behavior in public ((63, 64, 65) Maladaptive Behavior pg. 4)
1
2
3
4
5
7.
Go around cottage, ward, building, without
							 running away, wandering off, or becoming lost ((56) Sense of Direction pg. 2,
							 (57) Maladaptive Behavior pg. 4)
1
2
3
4
5
8.
Make minor purchases i.e., candy, soft
							 drink, etc. ((58, 4) Purchasing pg. 2)
1
2
3
4
5
Statutory Authority
§ 32.1-325 of the Code of Virginia.