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 12VAC30-60-301 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms as used in
				  12VAC30-60-302 through
				  12VAC30-60-315 shall have the
				  following meanings unless the context clearly indicates otherwise:
"Activities of daily living" or "ADLs" means personal care
				  tasks such as bathing, dressing, toileting, 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.
"Adult" means a person age 18 years or older who may need
				  Medicaid-funded long-term services and supports (LTSS) or who becomes
				  functionally eligible to receive Medicaid-funded LTSS.
"Appeal" means the processes used to challenge actions
				  regarding services, benefits, and reimbursement provided by Medicaid pursuant
				  to 12VAC30-110 and Part XII (12VAC30-20-500 et seq.) of 12VAC30-20.
"At risk" means the need for the level of care provided in a
				  hospital, nursing facility, or an intermediate care facility for individuals
				  with intellectual disability (ICF/IID) when there is reasonable indication that
				  the individual is expected to need the services in the near future (that is, 30
				  days or less) in the absence of home or community-based services.
"Child" means a person up to the age of 18 years who may need
				  Medicaid-funded LTSS or who becomes functionally eligible to receive
				  Medicaid-funded LTSS.
"Choice" means the individual is provided the option of
				  either home and community-based waiver services or institutional services and
				  supports, including the Program of All-Inclusive Care for the Elderly (PACE),
				  if available and appropriate, after the individual has been determined likely
				  to need LTSS.
"Communication" means all forms of sharing information and
				  includes oral speech and augmented or alternative communication used to express
				  thoughts, needs, wants, and ideas, such as the use of a communication device,
				  interpreter, gestures, and picture or symbol communication boards.
"Community-based team" or "CBT" means (i) a registered nurse
				  or nurse practitioner; (ii) a social worker or other assessor designated by
				  DMAS; and (iii) a physician. The CBT members are employees of, or contracted
				  with, the Virginia Department of Health or the local department of social
				  services.
"CSB" means a local community services board.
"DARS" means the Virginia Department for Aging and
				  Rehabilitative Services.
"Day" means calendar day unless specified otherwise.
"DBHDS" means the Virginia Department of Behavioral Health
				  and Developmental Services.
"DMAS" means the Department of Medical Assistance
				  Services.
"DMAS designee" means the public or private entity with an
				  agreement with the Department of Medical Assistance Services to complete
				  preadmission screenings pursuant to §
									32.1-330
				  of the Code of Virginia.
"ePAS" means the DMAS automated system or a DMAS-approved
				  electronic record system for use by entities contracted by DMAS to perform
				  screenings pursuant to §
									32.1-330
				  of the Code of Virginia.
"Face-to-face" means an in-person meeting with the individual
				  seeking Medicaid-funded LTSS.
"Feasible alternative" means a range of services that can be
				  provided in the community via waiver or PACE, for less than the cost of
				  comparable institutional care, in order to enable an individual to continue
				  living in the community.
"Functional capacity" means the degree of independence that
				  an individual has in performing ADLs, ambulation, and instrumental ADLs as
				  measured on the UAI and as used as a basis for differentiating levels of
				  long-term care services.
"Functional eligibility" means the demonstrable degree to
				  which an individual requires assistance with activities of daily living.
"Home and community-based services" means community-based
				  waiver services or the Program of All-Inclusive Care for the Elderly
				  (PACE).
"Home and community-based services provider" means a provider
				  or agency enrolled with Virginia Medicaid to offer services to individuals
				  eligible for home and community-based waivers services or PACE.
"Home and community-based services waiver," "HCBS," or
				  "waiver services" means the range of community services and supports, including
				  PACE, approved by the Centers for Medicare and Medicaid Services (CMS) pursuant
				  to § 1915(c) of the Social Security Act to be offered to individuals as an
				  alternative to institutionalization.
"Hospital team" means persons designated by the hospital who
				  are responsible for conducting and submitting the screening documents for
				  inpatients to ePAS.
"Inpatient" means an individual who has a physician's order
				  for admission to an acute care hospital, rehabilitation hospital, or a
				  rehabilitation unit in an acute care hospital and shall not apply to
				  outpatients, patients in observation beds, and patients of the hospital's
				  emergency department.
"Local department of social services" or "LDSS" means the
				  entity established under §
									63.2-324
				  of the Code of Virginia by the governing city or county in the
				  Commonwealth.
"Local health department" or "LHD" means the entity
				  established under §
									32.1-31
				  of the Code of Virginia.
"Long-term services and supports" or "LTSS" means a variety
				  of services that help individuals with health or personal care needs and ADLs
				  over a period of time that can be provided in the home, the community, or
				  nursing facilities.
"Managed care organization" or "MCO" means a health plan
				  selected to participate in the Commonwealth's CCC Plus program and that is a
				  party to a contract with DMAS.
"Medicaid" means the program set out in the
				  42 USC §
										1396 et seq. and administered by the
				  Department of Medical Assistance Services consistent with Chapter 10 (§
									32.1-323
				  et seq.) of Title 32.1 of the Code of Virginia.
"Medical or nursing need" means (i) the individual's
				  condition requires observation and assessment to ensure evaluation of needs due
				  to an inability for self-observation or evaluation; (ii) the individual has
				  complex medical conditions that may be unstable or have the potential for
				  instability; or (iii) the individual requires at least one ongoing medical or
				  nursing service.
"Medicare" means the Health Insurance for the Aged and
				  Disabled program as administered by the Centers for Medicare and Medicaid
				  Services pursuant to
				  42
				  USC 1395gg g.
"Minimum data set" or "MDS" means the evaluation form used
				  by nursing facilities, as federally required, for the purpose of documenting
				  ongoing level of care required for all of an NF's residents.
"Nursing facility" or "NF" means any nursing home as defined
				  in §
									32.1-123 of the Code
				  of Virginia.
"Ongoing" means continuous medical or nursing needs that
				  shall not be temporary.
"Other assessor designated by DMAS" means an employee of the
				  local department of social services holding the occupational title of family
				  services specialist or an employee of a DMAS designee.
"Preadmission screening" or "screening" means the
				  face-to-face process to (i) evaluate the functional, medical or nursing, and
				  social support needs of individuals referred for screening for certain
				  long-term care services requiring NF eligibility; (ii) assist individuals in
				  determining what specific services the individual needs; (iii) evaluate whether
				  a service or a combination of existing community services are available to meet
				  the individual's needs; and (iv) provide a list to individuals of appropriate
				  providers for Medicaid-funded nursing facility or home and community-based
				  services for those individuals who meet nursing facility level of care.
"Private pay individual" means individuals who are not
				  eligible for Medicaid or not expected to become eligible for Medicaid within
				  six months following admission.
"Program of All-Inclusive Care for the Elderly" or "PACE"
				  means the community-based service pursuant to §
									32.1-330.3
				  of the Code of Virginia.
"Provider" means an individual professional or an agency
				  enrolled with Virginia Medicaid to offer services to eligible
				  individuals.
"Referral for screening" means information obtained from an
				  interested person or other third party having knowledge of an individual who
				  may need Medicaid-funded LTSS and may include, for example, a physician, PACE
				  provider, service provider, family member, or neighbor who is able to provide
				  sufficient information to enable contact with the individual.
"Representative" means a person who is authorized to make
				  decisions on behalf of the individual.
"Request date for screening" or "request date" means the date
				  (i) that an individual, an emancipated child, the individual's representative,
				  an adult protective services worker, child protective services worker,
				  physician, or the managed care organization (MCO) care coordinator contacts the
				  screening entity in the jurisdiction where the individual resides asking for
				  assistance with LTSS, or (ii) for hospital inpatients, that a physician orders
				  case management consultation or a hospital's case management service determines
				  the need for LTSS upon discharge from the hospital.
"Request for screening" means (i) communication from an
				  individual, an emancipated child, individual's representative, adult protective
				  services worker, child protective services worker, physician, managed care
				  organization (MCO) care coordinator, or CSB support coordinator, expressing the
				  need for LTSS or (ii) for hospital inpatients, a physician order for case
				  management consultation or case management determination of the need for LTSS
				  upon discharge from a hospital.
"Residence" means the location in which an individual is
				  living, for example, an individual's private home, apartment, assisted living
				  facility, nursing facility, jail or correctional facility.
"Screening entity" means the hospital screening team,
				  community-based team, or DMAS designee contracted to perform screenings
				  pursuant to §
									32.1-330
				  of the Code of Virginia.
"Significant change in condition" means a change in an
				  individual's condition that is expected to last longer than 30 days and shall
				  not include (i) short-term changes that resolve with or without intervention;
				  (ii) a short-term illness or episodic event; or (iii) a well-established,
				  predictive, cyclic pattern of clinical signs and symptoms associated with a
				  previously diagnosed condition where an appropriate course of treatment is in
				  progress.
"Submission" means the transmission of the screening findings
				  via ePAS.
"Uniform Assessment Instrument" or "UAI" means the
				  standardized multidimensional assessment instrument that is completed by the
				  screening entity that assesses an individual's physical health, mental health,
				  and psycho/social and functional abilities to determine if the individual meets
				  the nursing facility level of care.
"VDH" means the Virginia Department of Health.
Statutory Authority: §
											32.1-325
					 of the Code of Virginia;
					 42 USC §
												1396 et
					 seq.