Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 122 - COMMUNITY WAIVER SRVICES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES › Section 12VAC30-122-120 - Provider requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				Providers approved for participation shall at a minimum perform the following
				activities:
1. On a monthly basis, screen and
				document the names of 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 U.S. Department of
				Health and Human Services Office of Inspector General List of Excluded
				Individuals and Entities (LEIE) website). Immediately upon learning of an
				exclusion, report in writing to DMAS such exclusion information to: DMAS, ATTN:
				Program Integrity/Exclusions, 600 East Broad Street, Suite 1300, Richmond, VA
				23219 or email to providerexclusion@dmas.virginia.gov.
2. Immediately notify DMAS in writing of any
				change in the information that the provider previously submitted for the
				purpose of the provider agreement to DMAS.
3. Assure the individual's freedom to refuse
				medical care, treatment, and services and document that potential adverse
				outcomes that may result from refusal of services were discussed with the
				individual.
4. Accept referrals for
				services only when staff is available to initiate services within 30 calendar
				days of the referral and perform such services on an ongoing basis.
5. Accept training on Crisis Education and
				Prevention Plans (CEPPs) by DBHDS, or its contractor, based on individual
				needs.
6. Participate in the
				completion of Quality Service Reviews conducted by DBHDS or its contractor.
7. Provide medically necessary
				services and supports for individuals in accordance with the ISP and in full
				compliance with 42 CFR 441.301, which provides for person-centered planning and
				other requirements for home and community-based settings including the
				additional requirements for provider-owned and controlled residential settings;
				Title VI of the Civil Rights Act of 1964, as amended (
				42
				USC §
											2000d et seq.), which prohibits
				discrimination on the grounds of race, color, or national origin; the
				Virginians with Disabilities Act (Title 51.5 (§
										51.5-1 et
				seq.) of the Code of Virginia); § 504 of the Rehabilitation Act of 1973,
				as amended (
				29 USC §
											794 ), which prohibits discrimination on the
				basis of a disability; and the Americans with Disabilities Act, as amended (
				42 USC §
											12101 et seq.).
8. Provide services and supports to
				individuals of the same quality and in the same mode of delivery as provided to
				the general public.
9. In addition
				to compliance with the general conditions and requirements, all providers
				enrolled by DMAS shall adhere to the requirements outlined in federal and state
				laws, regulations, DMAS provider manuals, and their individual provider
				participation agreements.
10.
				Submit reimbursement claims to DMAS for the provision of covered services and
				supplies for 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 the DMAS payment methodology from the individual's
				authorization date for that waiver service.
11. Use program-designated billing forms for
				submission of claims for reimbursement.
12. Maintain and retain business records
				(e.g., licensing or certification records as appropriate) and professional
				records (e.g., staff training and criminal record check documentation). All
				providers, including services facilitation providers, shall also document fully
				and accurately the nature, scope, and details of the services provided to
				support claims for reimbursement. Provider documentation that fails to fully
				and accurately document the nature, scope, and details of the services provided
				may be subject to recovery actions by DMAS or its designee. Provider
				documentation responsibilities include the following:
a. Retain records for at least six years from
				the last date of service or as provided by applicable state and federal laws,
				whichever period is longer. Records of minors shall be kept for at least six
				years after such minor has reached the age of 18 years.
b. If an audit is initiated of the provider's
				records within the required retention period, the records shall be retained
				until the audit is completed and every exception resolved. No business or
				professional records that are subject to the audit shall be created or modified
				by providers, employees, or any other interested parties, either with or
				without the provider's knowledge, once an audit has been initiated.
c. Policies regarding retention of records
				shall apply even if the provider discontinues operation. Providers shall notify
				DMAS in writing of storage, location, and procedures for obtaining records for
				review should the need arise. The location, agent, or trustee of the provider's
				records shall be within the Commonwealth of Virginia.
d. Providers shall develop a plan for
				supports that shall include at a minimum for each individual enrolled in one of
				the three DD Waivers:
(1) The individual's
				desired outcomes that describe what is important to and for the individual in
				observable terms;
(2) Support
				activities and support instructions that are inclusive of skill-building as may
				be required by the service provided and that are designed to assist in
				achieving the individual's desired outcomes;
(3) The services to be rendered and the
				schedule for such services to accomplish the desired outcomes and support
				activities, a timetable for the accomplishment of the individual's desired
				outcomes and support activities, the estimated duration of the individual's
				need for services, and the provider staff responsible for overall coordination
				and integration of the services specified in the plan for supports;
				and
(4) Documentation regarding any
				restrictions on the freedoms of everyday life in accordance with 12VAC35-115,
				Regulations to Assure the Rights of Individuals Receiving Services from
				Providers Licensed, Funded, or Operated by the Department of Behavioral Health
				and Developmental Services and the requirements of 42 CFR 441.301.
e. Providers shall
				prepare and maintain unique person-centered written documentation in the form
				of progress notes or supports checklist as defined by the service. These shall
				be in each individual's record about the individual's responses to supports and
				specific circumstances that prevented provision of the scheduled service,
				should that occur. Such documentation shall be provided to DMAS or its designee
				upon request. Such documentation shall be written, signed, and dated on the day
				the described supports were provided. Documentation that occurs after the date
				services were provided shall be dated with the date the documentation was
				completed and also include the date the services were provided within the body
				of the note. In instances when the individual does not communicate through
				words, the provider shall note his observations about the individual's
				condition and observable responses, if any, at the time of service
				delivery.
f. Unacceptable
				person-centered progress notes include:
(1)
				Standardized or formulaic notes;
(2) Notes copied from previous service dates
				and simply redated;
(3) Notes that
				are not signed and dated by staff who deliver the service, with the date
				services were rendered; and
(4)
				Person-centered progress notes that do not document the individual's unique
				opinions or observed responses to supports.
g. Providers shall maintain an attendance log
				or similar document that indicates the date services were rendered, type of
				services rendered, and number of hours or units provided (including specific
				timeframe for services with a unit of service shorter than one day ) for each
				service type except for one-time services such as assistive technology service,
				environmental modifications service, transition service, individual and family
				caregiver training service, electronic home-based support service, services
				facilitation service, and personal emergency response system support service,
				where initial documentation to support claims shall
				suffice.
13. Agree to
				furnish information and record documentation on request and in the form
				requested to DMAS, DBHDS, the Attorney General of Virginia or his authorized
				representatives, federal personnel (e.g., Office of the Inspector General), and
				the State Medicaid Fraud Control Unit. The Commonwealth's right of access to
				provider premises and records shall survive any termination of the provider
				participation 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 individuals
				enrolled in Medicaid.
15. Perform
				criminal history record checks for barrier crimes in accordance with applicable
				licensure requirements at §§
										37.2-416,
				37.2-506,
				and
				37.2-607
				of the Code of Virginia, as applicable. If the individual enrolled in the
				waiver is a minor child, also perform a search of the VDSS Child Protective
				Services Central Registry. The provider shall not be compensated for services
				provided to the individual enrolled in the waiver effective on the date and
				afterwards that any of these records checks verifies that the staff person
				providing services was ineligible to do so pursuant to the applicable statute.
a. For consumer-directed (CD) services, the
				CD employee shall submit to a criminal history records check conducted by the
				DMAS designated fiscal employer agent. The CD employee shall be compensated for
				up to 30 days of employment while the background check is being processed or to
				the date on which the background check verifies that the CD employee has been
				convicted of a barrier crime pursuant to §
											37.2-416
				of the Code of Virginia or if the CD employee has a founded complaint confirmed
				by the VDSS Child Protective Services Central Registry (if applicable),
				whichever comes first.
b. The CD
				employer of record shall require CD employees to notify the employer of record
				of all convictions occurring subsequent to the initial record check. CD
				employees who refuse to consent to criminal background checks and VDSS Child
				Protective Services registry checks shall not be eligible for Medicaid
				reimbursement.
16.
				Report suspected abuse or neglect immediately at first knowledge to the local
				Department for Aging and Rehabilitative Services, adult protective services
				agency or the local department of social services, child protective services
				agency; to DMAS or its designee; and to the DBHDS Office of Human Rights, if
				applicable pursuant to §§
										63.2-1509
				and
				63.2-1606
				of the Code of Virginia when the participating provider knows or suspects that
				an individual receiving home and community-based waiver services is being
				abused, neglected, or exploited.
17. Refrain from engaging in any type of
				direct marketing activities to Medicaid individuals or their
				families/caregivers. "Direct marketing" means (i) conducting directly or
				indirectly door-to-door, telephonic, or other cold call marketing of services
				at residences and provider sites; (ii) mailing directly; (iii) paying finder's
				fees; (iv) offering financial incentives, rewards, gifts, or special
				opportunities to eligible individuals and the individual's family/caregivers,
				as appropriate, as inducements to use the provider's services; (v) continuous,
				periodic marketing activities to the same prospective individual and the
				individual's family/caregiver, for example, monthly, quarterly, or annual
				giveaways, as inducements to use the provider's services; or (vi) engaging in
				marketing activities that offer potential customers rebates or discounts in
				conjunction with the use of the provider's services or other benefits as a
				means of influencing the individual and the individual's family/caregivers use
				of the provider's services.
18.
				Providers shall ensure that staff providing waiver services read and write
				English to the degree required to create and maintain the required
				documentation.
19. Providers shall
				document and maintain written semiannual supervision notes for each DSP and
				supervisor of DSPs that are signed and dated by the supervisor. Additionally,
a. For DBHDS-licensed entities, the provider
				shall provide ongoing supervision of all DSP staff, including those employees
				such as supervisors, that are directly involved with individuals being served,
				consistent with the requirements of 12VAC35-105.
b. For providers who are licensed by VDH or
				have accreditation from a CMS-recognized organization to be a personal care or
				respite care provider, they shall provide ongoing supervision of companion or
				DSP staff consistent with those regulatory requirements.
20. Providers shall ensure that all employees
				or contractors without pertinent or medical clinical licenses who will be
				responsible for medication administration demonstrate competency of this set of
				skills under direct observation prior to performing this task without direct
				supervision.
21. DBHDS-licensed
				providers shall ensure all employees or contractors who will be responsible for
				performing de-escalation or behavioral interventions demonstrate competency of
				this set of skills under direct observation prior to performing these tasks
				with any individual service recipient.