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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
11/21/2024

12VAC30-60-315. Periodic evaluations for individuals receiving Medicaid-funded long-term services and supports.

A. Once an individual is enrolled in home and community-based services, the home and community-based services provider shall be responsible for conducting periodic evaluations to ensure that the individual meets, and continues to meet, the waiver program or PACE criteria, if appropriate. These periodic evaluations shall be conducted using the DMAS Care Management Solution (CRMS) module of the Department’s Medicaid Enterprise System. The home and community-based services provider shall promptly evaluate the individual after the individual experiences a significant change in his condition, as defined in 12VAC30-60-301.

B. Once an individual has been screened for LTSS and is enrolled in LTSS in an NF, the NF shall be responsible for conducting periodic evaluations to ensure that the individual meets, and continues to meet, the NF criteria. For this purpose, the NF shall use the federally required Minimum Data Set (MDS) form (see https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html). For individuals screened for LTSS by hospital teams and CBTs and admitted directly into NF LTSS, the individual shall be evaluated using the MDS no later than 14 days after the date of NF admission. Any individual receiving NF LTSS who experiences a significant change in the individual's condition, as defined in 12VAC30-60-301, shall be evaluated using the MDS.

For individuals admitted to skilled or rehabilitation services in an NF, the NF shall be responsible for conducting periodic evaluations to ensure that the individual meets and continues to meet criteria. For this purpose, the NF shall use the federally required MDS form (see https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html). The post-enrollment evaluation shall be conducted no later than 14 days after the date of the NF admission and promptly after a significant change in the individual's condition, as defined in 12VAC30-60-301.

C. For individuals who are enrolled in an MCO that is responsible for providing LTSS, the MCO shall conduct periodic evaluations by qualified MCO staff to ensure the individual continues to meet criteria for LTSS. The MCO shall promptly evaluate the individual after he experiences a significant change in his condition, as defined in 12VAC30-60-301.

D. If an individual has been screened for LTSS and enrollment in LTSS has not occurred within one year of the completion date of the LTSS screening, a new LTSS screening shall be conducted to document the level of care and ensure continued need for services.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Historical Notes

Derived from Virginia Register Volume 34, Issue 24, eff. August 22, 2018; amended, Virginia Register Volume 41, Issue 1, eff. October 10, 2024.

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