Virginia Law

A. Service description.

1. Respite service is temporary, substitute care that is normally provided on a short-term basis for temporary relief of the primary caregiver.

2. Respite service enables an individual to maintain the health status and functional skills necessary to live in the community or participate in community activities.

3. Respite service may be provided either through an agency-directed or consumer-directed model. Respite service shall be provided:

a. In home and community settings, which may be based in the individual's home; or

b. Under the agency-directed model by enrolled providers licensed to provide center-based respite service, to include a group home or a sponsored residential home.

4. Respite service shall be covered in the FIS and CL waivers.

B. Criteria.

1. To qualify for respite service, the individual shall demonstrate (i) a need for assistance with ADLs, community access, self-administration of medications or other medical needs, or monitoring of health status or physical condition and (ii) the family or other unpaid caregiver has expressed the need for relief of caregiving duties.

2. The need for respite service shall be documented in the plan for supports.

3. Allowable activities shall include:

a. Assistance support with ADLs and IADLs;

b. Support with monitoring of health status or physical condition;

c. Support with prescribed use of medication and other medical needs;

d. Support with preparation and eating of meals;

e. Support with housekeeping activities, such as bed-making, cleaning, or the individual's laundry;

f. Safety supports;

g. Support with participation in social, recreational, and community activities;

h. Accompanying the individual to appointments or meetings; and

i. Assistance with bowel/bladder care needs, range of motion activities, routine wound care that does not include sterile technique, and external catheter care when trained and supervised by an RN.

4. Individuals may receive both agency-directed and consumer-directed personal assistance as long as the two service models do not overlap the same days and times.

5. Individuals choosing the consumer-directed option for respite service may receive support from a services facilitator and shall meet requirements for consumer direction as described in 12VAC30-122-150.

C. Service units and service limitations.

1. The unit of service shall be one hour. Respite service shall be limited to 480 hours per individual per state fiscal year. If an individual changes waiver programs, this same maximum number of respite hours shall apply. No additional respite hours beyond the 480 hours maximum limit shall be approved for payment. Individuals who are receiving respite service in the FIS or CL waivers through both the agency-directed and consumer-directed models shall not exceed 480 hours per year combined.

2. A person rendering respite service for reimbursement by DMAS shall meet the requirements set forth in 12VAC30-122-120 B.

3. Any combination of companion service, personal assistance service, and respite service delivered by a single assistant or companion to one individual in the consumer-directed service model shall be limited to 40 hours per week for an employer of record (EOR). Assistants who live with the individual, either full time or for substantial amounts of time, shall not be restricted to only 40 hours per week for the EOR. Individuals may receive more than 40 hours per week, if needed, of respite service from multiple assistants. The assistant shall not provide more than 16 hours of consumer-directed services per day. The 16-hour limit shall include hours worked in one day providing a combination of companion, personal assistance, and respite services.

4. When specified in the provider's plan for supports, such supportive service may include assistance with IADLs. Respite assistance shall not include skilled nursing service, with the exception of skilled nursing tasks that are delegated pursuant to 18VAC90-19-240 through 18VAC90-19-280, regulated in Chapters 30 (§ 54.1-3000 et seq.) and 34 (§ 54.1-3400 et seq.) of Title 54.1 of the Code of Virginia, as appropriate.

5. Respite service shall not be provided for DMAS reimbursement to relieve staff of group homes, supported living service, or sponsored residential service, as defined by 12VAC35-105-20, or assisted living facilities, as defined by 22VAC40-73-10, where residential supports are provided in shifts. Respite service shall not be provided for DMAS reimbursement by adult foster care providers for an individual residing in that foster home.

6. Skill development shall not be provided with respite service.

7. The hours to be authorized shall be based on the individual's need. Two individuals in the same home may share supports delivered by one assistant; however, the number of hours billed shall not exceed the number of hours the assistant worked.

8. Consumer-directed and agency-directed respite service shall meet the same standards for service limits and authorizations.

D. Provider requirements.

1. Providers shall meet the requirements in 12VAC30-122-110 through 12VAC30-122-140.

2. For agency directed respite service, the provider shall (i) be licensed by DBHDS as a center-based respite service provider, supportive in-home respite service provider, out-of-home respite service provider, or residential respite service provider; (ii) a VDSS-certified foster care home for children or a VDSS-certified adult foster care home for individuals who do not reside in that foster home; (iii) meet the Virginia Department of Health (VDH) licensing requirements; or (iv) have accreditation from a CMS-recognized organization to be a personal care or respite care provider.

3. Providers of agency-directed respite service shall have a current, signed participation agreement with DMAS. Providers designated on this agreement shall render this service directly and shall bill DMAS directly for Medicaid reimbursement.

4. For respite service, the service provider shall complete:

a. An assessment for all individuals prior to admission to services.

b. A plan for supports.

c. Any subsequent reassessments or changes to the plan for supports. All changes that are indicated for an individual's plan for supports shall be reviewed with and agreed to by the individual and, if appropriate, the individual's family/caregiver.

5. Respite assistants shall:

a. Be at least 18 years of age or older;

b. Be able to read and write English to the degree necessary to perform the expected tasks and create and maintain the required documentation;

c. Be physically able to perform the required tasks and have the required skills to perform services as specified in the waiver individual's supporting documentation;

d. Have a valid Social Security Number that has been issued to the respite service provider by the Social Security Administration;

e. Meet the requirements of 12VAC30-122-120 A regarding criminal record checks and, if the waiver individual is a minor, consent to a search of the VDSS Child Protective Services Central Registry.

f. Understand and agree to comply with the DMAS DD Waiver requirements; and

g. Receive tuberculosis screening as specified in the criteria used by the VDH.

h. For consumer directed respite assistants, be willing to attend training at the individual's or family/caregiver's request.

6. Requirements for agency-directed assistants

a. Providers shall ensure that staff providing respite service meet provider training and competency requirements as specified in 12VAC30-122-180.

b. Assistants employed by DBHDS licensed agencies shall meet the requirements as specified in 12VAC35-105-420.

c. Assistants employed by personal care agencies licensed by VDH or having accreditation from a CMS-recognized organization shall have completed an educational curriculum of at least 40 hours of study related to the needs of individuals who have disabilities, including intellectual and developmental disabilities, as ensured by the provider prior to being assigned to support an individual. Assistants shall have the required skills and training to perform the service as specified in the individual's plan for supports and related supporting documentation. An assistant's required training shall be met in one of the following ways:

(1) Registration with the Board of Nursing as a certified nurse aide;

(2) Graduation from an approved educational curriculum as listed by the Board of Nursing; or

(3) Completion of the provider's educational curriculum, as conducted by a licensed RN who shall have at least one year of related clinical nursing experience that may include work in an acute care hospital, public health clinic, home health agency, ICF/IID, or nursing facility.

d. Assistants shall have a satisfactory work record, as evidenced by two references from prior job experiences, if applicable, including no evidence of possible abuse, neglect, or exploitation of elderly persons, children, or adults with disabilities.

e. Persons functioning as assistants shall meet the requirements as specified in 12VAC5-381.

7. Supervision shall be provided to all DSPs and respite assistants.

a. Documentation of supervision shall be completed, signed, and dated by the supervisor and shall include, at a minimum, the following:

(1) Date of contact or observation;

(2) DSP contacted or observed; and

(3) A summary of the contact or observation.

b. When respite service is routine in nature, that is, occurring with a scheduled regularity for specific periods of time and offered in conjunction with personal assistance service, the supervisory visit conducted for personal assistance service may serve as the supervisory visit for the respite service. However, the supervisor shall document supervision of the respite service separately. For this purpose, the same individual record shall be used with a separate section clearly marked for respite service documentation.

c. Based on continuing evaluations of the assistant's performance and individual's needs, the supervisor shall identify any gaps in the assistant's ability to function competently and shall provide training as indicated.

8. Supervision requirements for agency-directed respite service.

a. A supervisor shall provide ongoing supervision of all respite assistants. For respite providers that are licensed by DBHDS, a supervisor meeting the requirements of 12VAC35-105-590 shall provide supervision of direct support professional staff.

b. For respite providers who are licensed by VDH or have accreditation from a CMS-recognized organization to be a personal care or respite care provider, the provider shall employ or subcontract with and directly supervise an RN or an LPN, or be an RN or LPN himself, who shall provide ongoing supervision of all assistants. The supervising RN or LPN shall have at least one year of related clinical nursing experience that may include work in an acute care hospital, public health clinic, home health agency, ICF/IID, or nursing facility.

9. For agency directed respite service provided based from the individual's home, in addition to 12VAC30-122-490 D 7:

a. The supervisor shall make a home visit to conduct an initial assessment prior to the start of service for all individuals enrolled in a DD Waiver who have been approved to receive respite service.

The supervisor shall make supervisory home visits or center-based visits to DBHDS-licensed settings as often as needed to ensure both quality and appropriateness of the service. When respite service is received on a routine basis, the minimum frequency of these supervisory visits shall be at least every 90 days under the agency-directed model, depending on the individual's needs. Documentation of supervision shall be completed, signed, and dated by the supervisor and shall include, at a minimum, the following:

When respite service is not received on a routine basis but is episodic in nature, the supervisor shall conduct the initial home visit with the respite

When respite service is routine in nature, that is, occurring with a scheduled regularity for specific periods of time and offered in conjunction with personal assistance service, the supervisory visit conducted for personal assistance service may serve as the supervisory visit for the respite service. However, the supervisor or service facilitator, as appropriate, shall document supervision of the respite service separately. For this purpose, the same individual record shall be used with a separate section clearly marked for respite service documentation.

b. If the individual is also attempting to access an assessment for personal assistance services, one assessment may be conducted for both services at the same time. However, the supervisor shall document supervision of the respite service separately. For this purpose, the same individual record shall be used with a separate section clearly marked for respite service documentation.

c. When the service is delivered on a routine basis, the minimum frequency of required supervisory visits shall be every 90 days.

d. When respite service is not received on a routine basis but is episodic in nature, the supervisor shall conduct the initial home visit with the DSP/respite assistant immediately preceding the start of service and make a second home visit within the respite service period. The supervisor or services facilitator, as appropriate, shall review the use of the respite service either every six months or upon the use of 240 respite service hours, whichever comes first.

10. For center-based respite service, in addition to 12VAC30-122-490 D 7, the supervisor shall provide ongoing supervision to all DSPs/respite assistants in DBHDS-licensed settings no less than quarterly to ensure both quality and appropriateness of the service.

11. Service facilitation requirements for respite service shall be the same as those set forth in 12VAC30-122-150.

Requirements for agency-directed assistants.

Assistants employed by personal assistance agencies licensed by VDH or having accreditation from a CMS-recognized organization shall have completed an educational curriculum of at least 40 hours of study related to the needs of individuals who have disabilities, including intellectual and developmental disabilities, as ensured by the provider prior to being assigned to support an individual. Assistants shall have the required skills and training to perform the service as specified in the individual's plan for supports and related supporting documentation. An assistant's required training shall be met in one of the following ways:

Assistants shall have a satisfactory work record, as evidenced by two references from prior job experiences, if applicable, including no evidence of possible abuse, neglect, or exploitation of elderly persons, children, or adults with disabilities.

When assistants are absent or otherwise unable to render scheduled supports to individuals enrolled in the waiver, the provider shall be responsible for ensuring that the service continues to be provided to the affected individuals.

During temporary, short-term lapses in coverage that are not expected to exceed approximately two weeks in duration, the following procedures shall apply:

If a provider secures a substitute assistant, the provider agency shall be responsible for ensuring that all DMAS requirements continue to be met, including documentation of service rendered by the substitute assistant and documentation that the substitute assistant's qualifications meet DMAS requirements. The two providers involved shall be responsible for negotiating the financial arrangements of paying the substitute assistant

12. For agency directed respite based in an individual's home, when assistants are absent or otherwise unable to render scheduled supports to individuals enrolled in the waiver, the provider shall be responsible for ensuring that the service continues to be provided to the affected individuals.

13. All individuals shall have a backup plan prior to initiating services in cases of emergency or should the provider be unable to render services as needed. This backup plan shall be documented and shared with the provider, services facilitator, and support coordinator at the onset of services and updated with the provider and support coordinator as necessary.

E. Service documentation and requirements .

1. Agency-directed providers shall maintain records regarding each individual who is receiving respite service.

2. At a minimum, the records shall contain:

a. A copy of the most recently completed age-appropriate assessment and, as needed, an initial assessment completed by the supervisor or services facilitator prior to or on the date service is initiated.

b. The provider and service facilitator's plan for supports per requirements detailed in 12VAC30-122-120.

c. A written review supported by documentation in the individual's record that is submitted to the support coordinator at least quarterly if services are delivered that quarter with the plan for supports if modified. For the annual review and in cases where the plan for supports is modified, the plan for supports shall be reviewed with and agreed to by the individual enrolled in the waiver and the individual's family/caregiver, as appropriate;

d. Supervisor's summarizing notes recorded and dated during any contacts with the assistant;

e. Documentation by the service supervisor in a summary note following significant contacts with the assistant and home visits with the individual the following:

(1) Whether the service continues to be appropriate;

(2) Whether the plan for supports is adequate to meet the individual's needs or changes are needed in the plan;

(3) The presence or absence of the assistant during the supervisor's visit if not a center-based service;

(4) Any suspected abuse, neglect, or exploitation and to whom it was reported; and

(5) Any hospitalization or change in medical condition, functioning, or cognitive status;

f. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS;

g. Contacts made with the individual's family/caregiver, physicians, providers, and all professionals concerning the individual; and

h. The specific service delivered to the individual enrolled in the waiver by the assistant dated the day of service delivery and the individual's unique, specific responses as well as:

(1) For home-based respite service, the respite assistant's arrival and departure times, in addition to the weekly signatures of the respite assistant, individual, and the individual's family member/caregiver, as appropriate, recorded on the last day of service delivery for any given week to verify that respite service during that week have been rendered.

(2) For center-based respite service, the individual's arrival and departure times from the center, group home, or sponsored residential site and documentation specific to 12VAC30-122-120 A 10 d.

(3). Respite service records shall be separated from those of other nonwaiver services, such as home health service.

(4) Progress notes shall meet the standards contained in 12VAC30-122-120 A.

(5) Consumer-directed documentation requirements are set forth in 12VAC30-122-500 E.

(6) Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.