Administrative Code

Virginia Administrative Code
7/21/2024

12VAC30-120-900. Definitions.

The following words and terms when used in this part 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 an individual who is 21 years of age or older.

"Adult day health care" or "ADHC" means a program licensed by the Virginia Department of Social Services (VDSS) as an adult day care center (ADCC) and authorized as a Medicaid-enrolled provider meeting home and community-based services (HCBS) settings rules that provides a variety of health, therapeutic, and social services designed to meet the specialized needs of those waiver individuals who are elderly or who have a disability and who are at risk of placement in a nursing facility (NF). ADHC can also refer to the center where this service is provided.

"Adult protective services" or "APS" means the same as defined in § 63.2-100 of the Code of Virginia.

"Agency-directed model " means a model of service delivery where an agency is responsible for providing direct support staff, for maintaining individuals' records, and for scheduling the dates and times of the direct support staff's presence in the individuals' homes for personal and respite care.

"Agency provider" means a public or private organization or entity that holds a Medicaid provider agreement and furnishes services to individuals using its own employees or subcontractors.

"Annually" means a period of time covering 365 consecutive calendar days or 366 consecutive days in the case of leap years.

"Appeal" means the process used to challenge actions regarding services, benefits, and reimbursement provided by Medicaid pursuant to 12VAC30-110 and 12VAC30-20-500 through 12VAC30-20-570.

"Applicant" means an individual or representative on the individual's behalf who has applied for or is in the process of applying for and is awaiting a determination of eligibility for admission to the CCC Plus Program Waiver.

"Assess" means to evaluate an applicant's or an individual's condition, including functional status (i.e., an individual's degree of dependence in performing ADLs or IADLs), current medical status, psychosocial history, and environment. Information is collected from the applicant or individual, applicant's or individual's representative, family, and medical professionals as well as the assessor's observation of the applicant or individual.

"Assessment" means one or more processes that are used to obtain information about an individual, including the individual's condition, personal goals and preferences, functional limitations, health status, financial status, and other factors that are relevant to the determination of eligibility for service. An assessment is required for the authorization of and provision of services and for the development of the plan of care.

"Assistive technology" or "AT" means specialized medical equipment and supplies including those devices, controls, or appliances specified in the plan of care but not available under the State Plan for Medical Assistance that (i) enable individuals to increase their abilities to perform ADLs or IADLs and to perceive, control, or communicate with the environment in which the individuals live or (ii) are necessary to the proper functioning of the specialized equipment.

"Backup caregiver" means a secondary person who assumes the role of providing direct care to and support of the waiver individual in instances of emergencies and in the absence of the primary caregiver who is unable to care for the individual. The backup caregiver shall perform the duties needed by the waiver individual without compensation and shall be trained in the skilled needs and technologies required by the waiver individual. The backup caregiver shall be identified in the waiver individual's records.

"Backup plan" means a secondary network of supports to perform the duties needed by the waiver individual to ensure the individual's health, safety, and welfare should the paid caregiver be unable to provide such services. All waiver individuals are required to have a backup plan prior to initiation of services and ongoing, which shall be documented in the waiver individual's records. Those listed in the backup plan shall be trained in the skilled needs and technologies required by the waiver individual.

"Barrier crime" means those crimes as defined at § 19.2-392.02 of the Code of Virginia that would prohibit either the employment or the continuation of employment if a person is found, through a Virginia State Police criminal record check, to have been convicted of such a crime.

"Care coordinator" means a professional from one of the state's contracted managed care organizations who assists assigned individuals enrolled in the CCC Plus integrated care initiative using a team-based, person-centered approach to effectively manage an individual's medical, social, and behavioral conditions.

"CMS" means the Centers for Medicare and Medicaid Services, which is the unit of the U.S. Department of Health and Human Services that administers the Medicare and Medicaid programs.

"Child protective services" or "CPS" means the same as defined in § 63.2-100 of the Code of Virginia.

"Cognitive impairment" means a severe deficit in mental capability that affects a waiver individual's areas of functioning such as thought processes, problem solving, judgment, memory, or comprehension that interferes with such things as reality orientation, ability to care for self, ability to recognize danger to self or others, or impulse control.

"Commonwealth Coordinated Care Plus Program" or "CCC Plus" means the DMAS mandatory integrated care initiative for certain qualifying Medicaid members, including members who are dually eligible for Medicare and Medicaid and members receiving long-term services and supports (LTSS). The CCC Plus Program includes members who receive services through nursing facility (NF) care, specialized care NF, or long-stay hospitals, or from one of the four DMAS home and community-based services (HCBS) § 1915(c) waivers. Not all individuals in the CCC Plus Program will qualify for the CCC Plus Waiver.

"Community-based team" or "CBT" means the same as defined in 12VAC30-60-301.

"Congregate living arrangement" means a living arrangement in which three or fewer waiver individuals live in the same household and share receipt of health care services from the same provider.

"Congregate PDN" means skilled in-home nursing provided to three or fewer waiver individuals in the individuals' primary residence or a group setting.

"Consumer-directed attendant" means a person who provides, via the consumer-directed model of services, personal care or respite care, or any combination of these two services, and who is also exempt from workers' compensation.

"Consumer-directed" or "CD" means the model of service delivery for which the individual or the individual's employer of record, as appropriate, is responsible for hiring, training, supervising, and firing of the attendant or attendants who render the services that are reimbursed by DMAS.

"Critical incident" means any incident that threatens or impacts the well-being of a waiver individual. Critical incidents shall include the following incidents: medication errors, severe injury or fall, theft, suspected mental or physical abuse or neglect, financial exploitation, and death.

"Day" means, for the purposes of reimbursement, a 24-hour period beginning at 12 a.m. and ending at 11:59 p.m.

"DBHDS" means the Department of Behavioral Health and Developmental Services.

"Direct marketing" means any of the following: (i) conducting either directly or indirectly door-to-door, telephonic, or other "cold call" marketing of services at residences and provider sites; (ii) using direct mailing; (iii) paying "finders fees"; (iv) offering financial incentives, rewards, gifts, or special opportunities to eligible individuals, family, or caregivers as inducements to use a provider's services; (v) providing continuous, periodic marketing activities to the same prospective individual, family, or caregiver, for example, monthly, quarterly, or annual giveaways as inducements to use a provider's services; or (vi) engaging in marketing activities that offer potential customers rebates or discounts in conjunction with the use of a provider's services or other benefits as a means of influencing the individual's, family's, or caregiver's use of a provider's services.

"Direct medical benefit" means services or supplies that are proper and needed for the diagnosis or treatment of a medical condition; are provided for the diagnosis, direct care, and treatment of the condition; and meet the standards of professional medical practice.

"DMAS" means the Department of Medical Assistance Services.

"DMAS staff" means persons employed by the Department of Medical Assistance Services.

"Durable medical equipment and supplies" or "DME" means those items prescribed by the attending physician, generally recognized by the medical community as serving a diagnostic or therapeutic purpose to assist the waiver individual in the completion of everyday activities, and as being a medically necessary element of the service plan without regard to whether those items are covered by the State Plan for Medical Assistance.

"Early periodic screening, diagnosis, and treatment" or "EPSDT" means the benefit program administered by DMAS for individuals younger than 21 years of age in accordance with the definition set forth at 42 CFR 440.40 (b) and the requirements of 42 CFR 441, Subpart B.

"Employer of record" or "EOR" means the person who performs the functions of the employer in the consumer-directed model of service delivery. The EOR may be the individual, a family member, caregiver, or another person.

"Enrollment" means the process where an individual has been determined to meet the financial and categorical eligibility requirements for a Medicaid program or service, and the approving entity has verified the availability of services for the individual requesting waiver enrollment and services.

"Environmental modifications" or "EM" means physical adaptations to an individual's primary residence or primary vehicle that are necessary to ensure the individual's health, safety, and welfare or that enable the individual to function with greater independence and shall be of direct medical or remedial benefit to the individual. Such physical adaptations shall not be authorized for Medicaid payment when the adaptation is being used to bring a substandard dwelling up to minimum habitation standards.

"Fiscal/employer agent" or "F/EA" means a state agency or other entity as determined by DMAS that meets the requirements of 42 CFR 441.484 and the Virginia Public Procurement Act, § 2.2-4300 et seq. of the Code of Virginia.

"Guardian" means a person appointed by a court to manage the personal affairs of an incapacitated individual pursuant to Chapter 20 (§ 64.2-2000 et seq.) of Title 64.2 of the Code of Virginia.

"Health, safety, and welfare" means, for the purposes of this waiver, that an individual's right to receive a CCC Plus Waiver service is dependent on a determination that the waiver individual needs the service based on appropriate assessment criteria and a written plan of care, including having a backup plan of care, that demonstrates medical necessity and that services can be safely provided in the community or through the model of care selected by the individual.

"Home and community-based waiver services" or "waiver services" means the range of community support services approved by the CMS pursuant to § 1915(c) of the Social Security Act to be offered to individuals as an alternative to institutionalization.

"Institution" means a nursing facility, specialized care nursing facility, or long-stay hospital. Individuals who receive enrollment in the CCC Plus Waiver are deemed to meet the level of care necessary for residence in one of these institutions or are anticipated to need to be in one of these institutions within the next 30 days without the services of the waiver.

"Instrumental activities of daily living" or "IADLs" means tasks such as meal preparation, shopping, housekeeping, and laundry. An individual's degree of independence in performing these activities is a part of determining appropriate service needs.

"Level of care" or "LOC" means the specification of the minimum amount of assistance an individual requires in order to receive services in an institutional setting under the State Plan or to receive waiver services.

"License" means proof of official or legal permission issued by the government for an entity or person to perform an activity or service.

"Licensed Practical Nurse" or "LPN" means a person who is licensed or holds multi-state licensure to practice nursing pursuant to Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia.

"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.

"Long-term services and supports" or "LTSS" means a variety of services that help individuals with health or personal care needs and activities of daily living over a period of time. Long-term care can be provided in the home, in the community, or in various types of facilities, including nursing facilities and assisted living facilities.

"LTSS screening" means the process to (i) evaluate the functional, nursing, and social supports of individuals referred for screening for certain long-term care services and supports requiring nursing facility 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 an individual's needs; and (iv) provide a list to individuals of appropriate providers for Medicaid-funded nursing facility or home and community-based care for those individuals who meet nursing facility level of care.

"LTSS screening team" means the entity contracted with DMAS that is responsible for performing the screening process pursuant to § 32.1-330 of the Code of Virginia.

"Managed care organization" or "MCO" means the same as the definition of this term in 42 CFR 438.2 .

"Medicaid Long-Term Services and Supports Communication Form" or "DMAS-225" means the form used by the long-term care provider to report information about changes in an individual's eligibility and financial circumstances.

"Medically necessary" means those services or specialized medical equipment or supplies that are covered for reimbursement under either the State Plan for Medical Assistance or in a waiver program that are reasonable, proper, and necessary for the treatment of an illness, injury, or deficit; are provided for direct care of the condition or to maintain or improve the functioning of a malformed body part; and meet the standards of good professional medical practice as determined by DMAS.

"Medication monitoring" means an electronic device, which is only available in conjunction with personal emergency response systems, that reminds an individual to take medications at the correct dosages and times.

"Minor child" means an individual who is younger than 18 years of age.

"Monitoring" means the ongoing oversight of the provision of waiver and other services to determine that they are furnished according to the waiver individual's plan of care and effectively meet the individual's needs, thereby ensuring the individual's health, safety, and welfare. Monitoring activities may include telephone contact; observation; interviewing the individual or the trained individual representative, as appropriate, in person or by telephone; or interviewing service providers.

"Nurse supervisor" means a registered nurse (RN) or licensed professional nurse (LPN) hired or contracted by an agency to provide the supervisory responsibilities as outlined in the waiver to the agency's staff who perform personal care or respite care services to waiver individuals.

"Participating provider" or "provider" means an entity that meets the standards and requirements set forth by DMAS and has a current, signed provider participation agreement with DMAS or a managed care organization that has a signed contract with DMAS.

"Patient pay amount" means the portion of the individual's income that must be paid as the individual's share of the long-term services and supports and is calculated by the local department of social services based on the individual's documented monthly income and permitted deductions.

"Person-centered planning" means a fundamental process that focuses on what is important to and for an individual and the needs and preferences of the individual to create a plan of care.

"Personal care aide" or "aide" means a person employed by an agency who provides personal care or unskilled respite services. The aide shall have successfully completed an educational curriculum of at least 40 hours of study related to the needs of individuals who are either elderly or who have disabilities as further set out in 12VAC30-120-935. Such successful completion may be evidenced by the existence of a certificate of completion issued by the training entity, which is provided to DMAS during provider audits.

"Personal care attendant," "attendant," or "PCA" means a person who provides personal care or respite services that are directed by an employer of record under the CD model of service delivery.

"Personal care services" or "PC services" means a range of support services that includes assistance with ADLs or IADLs, access to the community, self-administration of medication or other medical needs, and the monitoring of health status and physical condition provided through the agency-directed or consumer-directed model of service. Personal care services shall be provided by aides or attendants within the scope of their licenses or certifications, as appropriate.

"Personal emergency response system" or "PERS" means an electronic device and monitoring service that enables certain waiver individuals who are at least 14 years of age and at risk of institutionalization to secure help in an emergency.

"PERS provider" means a certified home health or a personal care agency, a durable medical equipment provider, a hospital, or a PERS manufacturer that has the responsibility to furnish, install, maintain, test, monitor, and service PERS equipment, direct services (i.e., installation, equipment maintenance, and services calls), and PERS monitoring. PERS providers may also provide medication monitoring.

"Plan of care" or "POC" means the written plan developed collaboratively by the waiver individual and the waiver individual's family or caregiver, as appropriate, and the provider related solely to the specific services necessary for the individual to remain in the community while ensuring the individual's health, safety, and welfare.

"Private duty nursing services" or "PDN" means skilled in-home nursing services listed in the POC that are (i) not otherwise covered under the State Plan for Medical Assistance home health benefit; (ii) required to prevent institutionalization; or (iii) provided within the scope of the Commonwealth's Nurse Practice Act (Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia) and Drug Control Act ( Chapter 34 (§ 54.1-3400 et seq.) of Title 54.1 of the Code of Virginia).

"Provider agreement" means the contract between DMAS and a participating provider under which the provider agrees to furnish services to Medicaid-eligible individuals in compliance with state and federal statutes and regulations and Medicaid contract requirements.

"Registered nurse" or "RN" means a person who is licensed or who holds multi-state licensure privilege pursuant to Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia to practice nursing.

"Respite services" means services provided to waiver individuals that are furnished on a short-term basis because of the absence of or need for the relief of the unpaid primary caregiver who normally provides the care.

"Service authorization" means the process of approving a service for the individual. The process of approving is done by DMAS, its service authorization contractor, or an MCO.

"Service authorization contractor" means DMAS or the entity that has been contracted by DMAS, including an MCO, to perform service authorization for medically necessary Medicaid covered home and community-based services.

"Services facilitation" means a service that assists the waiver individual (or family, caregiver, or EOR, as appropriate) in arranging for, directing, training, and managing services provided through the consumer-directed model of service.

"Skilled private duty nursing services" or "skilled PDN" means skilled in-home nursing services listed in the POC that are (i) not otherwise covered under the State Plan for Medical Assistance home health benefit; (ii) required to prevent institutionalization; and (iii) provided within the scope of the Commonwealth's Nurse Practice Act (Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia) and Drug Control Act (Chapter 34 (§ 54.1-3400 et seq.) of Title 54.1 of the Code of Virginia).

"Skilled respite services" means temporary skilled nursing services that are provided to waiver individuals and that are performed by an LPN or RN for the relief of the unpaid primary caregiver who normally provides the care.

"State Plan for Medical Assistance" or "State Plan" means the Commonwealth's legal document approved by CMS identifying the covered groups, covered services and their limitations, and provider reimbursement methodologies as provided for under Title XIX of the Social Security Act.

"Transition services" means set-up expenses for individuals as defined at 12VAC30-120-2010.

"Unpaid primary caregiver" means the primary person who consistently assumes the primary role of providing direct care and support of the waiver individual to live successfully in the community without receiving compensation for providing such care.

"VDH" means the Virginia Department of Health.

"VDSS" means the Virginia Department of Social Services.

"Virginia Uniform Assessment Instrument" or "UAI" means the standardized multidimensional assessment that is completed by the screening entity that assesses an individual's physical health, mental health, and psychosocial and functional abilities to determine if the individual meets the nursing facility level of care.

"Waiver individual" or "individual" means the person who has applied for and been approved to receive these waiver services.

"Weekly" means a span of time covering seven consecutive calendar days.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; amended, Virginia Register Volume 25, Issue 20, eff. July 9, 2009; Volume 31, Issue 10, eff. February 12, 2015; Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-905. Waiver description and legal authority.

A. The Commonwealth Coordinated Care Plus (CCC Plus) Waiver operates under the authority of § 1915(c) of the Social Security Act and 42 CFR 430.25(b), which permit the waiver of certain State Plan requirements. These federal statutory and regulatory provisions permit the establishment of Medicaid waivers to afford the states with greater flexibility to devise different approaches to the provision of long-term services and supports. Under this § 1915(c) waiver, DMAS waives § 1902(a)(10)(B) and (C) of the Social Security Act related to comparability of services.

B. CCC Plus Waiver services shall be covered only for Medicaid-eligible individuals who have been determined eligible to require the level of care provided in either a nursing facility, specialized care nursing facility, or long-stay hospital. These services shall be the critical service necessary to delay or avoid the individual's placement in an appropriate facility.

C. Federal waiver requirements provide that the current aggregate average cost of care fiscal year expenditures under this waiver shall not exceed the average per capita expenditures in the aggregate for the level of care (LOC) provided in a nursing facility (NF), specialized care nursing facility, or long-stay hospital under the State Plan that would have been provided had the waiver not been granted.

D. DMAS shall be the single state agency authority, pursuant to 42 CFR 431.10, responsible for the processing and payment of claims for the services covered in this waiver and for obtaining federal financial participation from CMS.

E. Payments for CCC Plus Waiver services shall not be provided to any financial institution or entity located outside of the United States pursuant to § 1902(a)(80) of the Social Security Act. Payments for CCC Plus Waiver services furnished in another state shall be (i) provided for an individual who meets the requirements of 42 CFR 431.52 and (ii) limited to the same service limitations that exist when services are rendered within the Commonwealth's political boundaries. Waiver services shall not be covered for Medicaid-eligible individuals who are inpatients of a hospital, nursing facility (NF), intermediate care facility for individuals with intellectual disabilities (ICF/IID), rehabilitation hospitals, assisted living facility licensed by VDSS that serves five or more persons, long-stay hospitals, specialized care nursing facilities, adult foster homes, or group homes licensed by DBHDS.

F. An individual shall not be simultaneously enrolled in more than one waiver program but may be listed on the waiting list for another waiver program as long as criteria are met for both waiver programs.

G. DMAS shall be responsible for the following:

1. Placing individuals in appropriate services that are home and community based;

2. Providing reimbursement for waiver services only after the provider is enrolled and the individual's eligibility process is complete;

3. Not duplicating services that are required as a reasonable accommodation as a part of the Americans with Disabilities Act (42 USC §§ 12131 through 12165) or the Rehabilitation Act of 1973 (29 USC § 794). CCC Plus Waiver services shall not be authorized if another entity is required to provide the services (e.g., schools, insurance) because these waiver services shall not duplicate payment for services available through other programs or funding streams; and

4. Ensuring providers meet the following requirements:

a. Providers shall consider DMAS payment for services under this waiver as payment in full and no balance billing from the provider to the individual, any family member, caregiver, or the employer of record (EOR) of the waiver individual shall be permitted; and

b. Additional voluntary payments or gifts from family members shall not be accepted by providers of services.

H. DMAS or the designated service authorization contractor or managed care organization shall have the responsibility and the authority to terminate the receipt of home and community-based waiver enrollment for the waiver individual for any of the following reasons. Individuals shall be notified of their appeal rights pursuant to 12VAC30-110:

1. The home and community-based waiver services are no longer the critical alternative to prevent or delay institutional placement within 30 days;

2. The waiver individual is no longer eligible for Medicaid;

3. The waiver individual no longer meets the LOC criteria required for the waiver;

4. The waiver individual's environment in the community does not provide for the individual's health, safety, or welfare;

5. The waiver individual does not have a backup plan for services in the event the provider is unable to provide services; or

6. Any other circumstances that cause services to cease or be interrupted for more than 30 consecutive calendar days.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 31, Issue 10, eff. February 12, 2015; amended, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-910. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; amended, Virginia Register Volume 25, Issue 19, eff. July 1, 2009; Volume 25, Issue 20, eff. July 9, 2009; repealed, Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

12VAC30-120-920. Individual eligibility requirements.

A. Home and community-based waiver services shall be available through a § 1915(c) waiver of the Social Security Act for the following Medicaid-eligible individuals who have been determined to be eligible for waiver services and to require the level of care provided in a nursing facility (NF), long-stay hospital, or specialized care nursing facility:

1. Individuals who are elderly as defined by § 1614 of the Social Security Act; or

2. Individuals who have a disability as defined by § 1614 of the Social Security Act.

B. The Commonwealth has elected to cover low-income families with children as described in § 1931 of the Social Security Act; aged, blind, or disabled individuals who are eligible under 42 CFR 435.121; optional categorically needy individuals who are aged and disabled who have incomes at 80% of the federal poverty level; the special home and community-based waiver group under 42 CFR 435.217; and the medically needy groups specified in 42 CFR 435.320, 435.322, 435.324, and 435.330.

1. Under this waiver, the coverage groups authorized under § 1902(a)(10)(A)(ii)(VI) of the Social Security Act shall be considered as if the individual were institutionalized in an NF, specialized care NF, or long-stay hospital for the purpose of applying institutional deeming rules. All individuals in the waiver must meet the financial and nonfinancial Medicaid eligibility criteria and meet the institutional level of care (LOC) criteria. The deeming rules are applied to waiver eligible individuals as if the individual were residing in an institution or would require that level of care.

2. Virginia shall reduce its payment for home and community-based services provided to an individual who is eligible for Medicaid services under 42 CFR 435.217 by the amount of the waiver individual's total income (including amounts disregarded in determining financial eligibility) that remains after allowable deductions for personal maintenance needs, deductions for other dependents, and medical needs have been made, according to the guidelines in 42 CFR 435.735 and § 1915(c)(3) of the Social Security Act as amended by the Consolidated Omnibus Budget Reconciliation Act of 1986. DMAS shall reduce its payment for home and community-based waiver services by the amount that remains after the following deductions:

a. For waiver individuals to whom § 1924(d) applies (Virginia waives the requirement for comparability pursuant to § 1902(a)(10)(B)), deduct the following in the respective order:

(1) An amount for the maintenance needs of the waiver individual that is equal to 165% of the SSI income limit for one individual. Working individuals have a greater need due to expenses of employment; therefore, an additional amount of income shall be deducted. Earned income shall be deducted within the following limits: (i) for waiver individuals employed 20 hours or more per week, earned income shall be disregarded up to a maximum of both earned and unearned income up to 300% of SSI and (ii) for waiver individuals employed at least four but less than 20 hours per week, earned income shall be disregarded up to a maximum of both earned and unearned income up to 200% of SSI. However, in no case shall the total amount of income (both earned and unearned) that is disregarded for maintenance exceed 300% of SSI. If the waiver individual requires a guardian or conservator who charges a fee, the fee, not to exceed an amount greater than 5.0% of the waiver individual's total monthly income, is added to the maintenance needs allowance. However, in no case shall the total amount of the maintenance needs allowance (basic allowance plus earned income allowance plus guardianship fees) for the individual exceed 300% of SSI;

(2) For a waiver individual with only a spouse at home, the community spousal income allowance is determined in accordance with § 1924(d) of the Social Security Act;

(3) For an individual with a family at home, an additional amount for the maintenance needs of the family is determined in accordance with § 1924(d) of the Social Security Act; and

(4) Amounts for incurred expenses for medical or remedial care that are not subject to payment by a third party, including Medicare and other health insurance premiums, deductibles, or coinsurance charges and necessary medical or remedial care recognized under the state law but not covered under the State Plan.

b. For waiver individuals to whom § 1924(d) of the Social Security Act does not apply, deduct the following in the respective order:

(1) An amount for the maintenance needs of the waiver individual that is equal to 165% of the SSI income limit for one individual. Working individuals have a greater need due to expenses of employment; therefore, an additional amount of income shall be deducted. Earned income shall be deducted within the following limits: (i) for waiver individuals employed 20 hours or more, earned income shall be disregarded up to a maximum of 300% of SSI and (ii) for waiver individuals employed at least four but less than 20 hours, earned income shall be disregarded up to a maximum of 200% of SSI. However, in no case shall the total amount of income (both earned and unearned) that is disregarded for maintenance exceed 300% of SSI. If the individual requires a guardian or conservator who charges a fee, the fee, not to exceed an amount greater than 5.0% of the individual's total monthly income, is added to the maintenance needs allowance. However, in no case shall the total amount of the maintenance needs allowance (basic allowance plus earned income allowance plus guardianship fees) for the individual exceed 300% of SSI;

(2) For an individual with a family at home, an additional amount for the maintenance needs of the family that shall be equal to the medically needy income standard for a family of the same size; and

(3) Amounts for incurred expenses for medical or remedial care that are not subject to payment by a third party including Medicare and other health insurance premiums, deductibles, or coinsurance charges and necessary medical or remedial care recognized under state law but not covered under the State Plan.

C. Assessment and authorization of home and community-based waiver services.

1. To ensure that Virginia's home and community-based waiver programs serve only Medicaid eligible individuals who would otherwise be supported in an NF, specialized care NF, or long-stay hospital, home and community-based waiver services shall be considered only for individuals who are eligible for admission within 30 calendar days to one of these institutions. Home and community-based waiver services shall be the critical service to enable the individual to remain at home and in the community rather than being placed in an institution.

2. The individual's eligibility for home and community-based waiver services shall be determined by the LTSS screening team after completion of a thorough assessment of the individual's needs and available support. If the individual is determined eligible based on the procedures outlined in 12VAC30-60-303, the LTSS screening team shall provide the individual and family or caregiver with the choice of CCC Plus Waiver services, other appropriate services, institutional placement, or Program of All Inclusive Care for the Elderly (PACE) enrollment for people 55 years of age or older.

3. The LTSS screening team shall explore alternative settings or services to provide the care needed by the individual. If Medicaid-funded home and community-based waiver services are selected by the individual, the LTSS screening team shall initiate referrals for such services.

4. Medicaid shall not pay for any home and community-based waiver services delivered prior to the date the individual establishes Medicaid financial eligibility and the date of the LTSS screening with the physician's signature on the Medicaid Funded Long-Term Care Services Authorization Form (DMAS-96).

5. Before Medicaid shall assume payment responsibility of home and community-based services, service authorization must be obtained from DMAS or the DMAS-designated service authorization contractor for all services requiring service authorization. Providers shall submit all required information to DMAS or the designated service authorization contractor within 10 business days of initiating care or within 10 business days of receiving verification of Medicaid financial eligibility from the local department of social services. If the provider submits all required information to DMAS or the designated service authorization contractor within 10 business days of initiating care, services may be authorized beginning from the date the provider initiated services but not preceding the date of the physician's signature on the DMAS-96 form. If the provider does not submit all required information to DMAS or the designated service authorization contractor within 10 business days of initiating care, the services may be authorized beginning with the date all required information was received by DMAS or the designated service authorization contractor, but in no event preceding the date of the physician's signature on the DMAS-96 form.

6. Once waiver eligibility has been determined by the LTSS screening team and referrals have been initiated, the provider or MCO shall submit a Medicaid LTSS Communication Form (DMAS-225) to the local department of social services to determine financial eligibility for the waiver program and any patient pay responsibilities. If the waiver individual has a patient pay amount, a provider shall use the electronic patient pay process for the required monthly monitoring of relevant changes. Local departments of social services shall enter data regarding a waiver individual's patient pay amount obligation into the DMAS system of record at the time action is taken on behalf of the individual either as a result of an application for LTSS, redetermination of financial eligibility, or reported change or changes in a waiver individual's situation. Procedures for the verification of a waiver individual's patient pay obligation are available in the appropriate Medicaid provider manual.

7. After the provider or MCO has received notification via the DMAS-225 process by the local department of social services and enrollment confirmation from DMAS or the designated service authorization contractor, the provider shall inform the individual, family, or caregiver so that services may be initiated.

8. The provider or MCO shall be responsible for notifying the local department of social services via the DMAS-225 when there is an interruption of services for 30 consecutive calendar days or upon discharge or transfer from the provider's services.

9. Certain home and community-based services shall not be available to individuals residing in an assisted living facility licensed by VDSS that serves four or fewer individuals. These services are: respite, PERS, ADHC, environmental modifications, and transition services. Personal care services shall be covered for individuals living in these facilities but shall not exceed five hours per day. Personal care services shall be authorized based on the waiver individual's documented need for care over and above that which is provided by the assisted living facility.

10. Individuals who are receiving Auxiliary Grants shall not be eligible for CCC Plus Waiver enrollment or services.

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

12. Individuals who are receiving PDN waiver services shall have a trained primary caregiver who accepts responsibility for the individual's health, safety, and welfare. This primary caregiver shall be responsible for all hours not provided by an RN or an LPN. The name of the trained primary caregiver shall be documented in the provider's records.

D. Waiver individual responsibilities under the consumer-directed (CD) model.

1. The individual shall be authorized for CD services and the employer of record (EOR) shall successfully complete consumer employee management training performed by the services facilitator before the waiver individual or EOR shall be permitted to hire a personal care attendant for Medicaid reimbursement. Any services rendered by an attendant prior to dates authorized by Medicaid shall not be eligible for reimbursement. Individuals who are eligible for CD services shall have the capability to hire and train their own personal care attendants and supervise the attendants' performance including creating and maintaining complete and accurate work shift entries. The EOR may be the individual or a family member, caregiver, or another person designated by the individual to serve on the individual's behalf.

2. The person who serves as the EOR shall not be permitted to be (i) the paid attendant for respite services or personal care services or (ii) the services facilitator.

3. Individuals shall not knowingly continue to accept CD personal care services when the service is no longer appropriate or necessary for their care needs and shall inform the services facilitator. If CD services continue after services have been terminated by DMAS or the designated service authorization contractor, the waiver individual shall be held liable for attendant compensation.

4. The individual or EOR, as appropriate, shall notify the services facilitator of all hospitalizations and admission to any rehabilitation hospital unit, NF, specialized care NF, or long-stay hospital as soon as possible. Failure to do so may result in the waiver individual being liable for employee compensation.

E. Waiver individuals' rights and responsibilities. DMAS shall ensure that:

1. Each waiver individual shall receive, and the provider shall provide, the necessary care and services, to the extent of provider availability, to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the person-centered planning of the individual's comprehensive assessment and plan of care (POC).

2. Waiver individuals shall have the right to participate in the development of the plan of care and to receive services from the provider with reasonable accommodation of the individual's needs and preferences except when DMAS makes a determination that the health, safety, or welfare of the waiver individual or other individuals would be endangered.

3. All waiver individuals shall have the right to:

a. Voice grievances to the provider or provider staff without discrimination or reprisal. Such grievances include those with respect to treatment that has or has not been furnished;

b. Prompt efforts by the provider or staff, as appropriate, to resolve any grievances the waiver individual may have;

c. Be free from verbal, sexual, physical, and mental abuse, neglect, exploitation, and misappropriation of property;

d. Be treated with respect and with due consideration for the individual's dignity and privacy;

e. Be free from any physical or chemical restraints or seclusion of any form that may be used as a means of coercion, discipline, convenience, or retaliation and that are not required to treat the individual's medical symptoms;

f. The privacy and confidentiality of the individual's medical and clinical records; and

g. Receive information, such as a handbook or provider directory, in a manner and format that may be easily understood (i.e., in prevalent non-English languages and using translation services) and that is readily accessible in accordance with the standards specified in 42 CFR 438.10.

4. The waiver individual if legally competent, the waiver individual's legal guardian, or the parent of the minor child shall have the right to:

a. Choose whether the individual wishes to receive home and community-based care waiver services instead of institutionalization in accordance with the assessed needs of the individual. The LTSS screening team or MCO shall inform the individual of all available waiver service providers in the community in which the waiver individual resides. The waiver individual shall have the option of selecting the provider and services of the individual's choice. Individuals enrolled in the CCC Plus Program shall have the option of selecting a provider in the MCO's contracted network and services of the individual's choice. This choice must be documented in the individual's medical record;

b. Choose a primary care physician in the community in which the individual resides;

c. Be fully informed in advance about the waiver POC and treatment needs as well as any changes in that care or treatment that may affect the individual's well-being;

d. Participate in the care planning process, choice, and scheduling of providers and services; and

e. Be provided care with privacy, dignity, and respect at all times.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; amended, Virginia Register Volume 22, Issue 24, eff. September 6, 2006; Volume 25, Issue 20, eff. July 9, 2009; Volume 31, Issue 10, eff. February 12, 2015; Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-924. Covered services; limits on covered services.

A. Covered services in the CCC Plus Waiver are as follows: adult day health care; personal care (both consumer-directed and agency-directed); respite services (both consumer-directed and agency-directed); PERS services, including medication monitoring; services facilitation; private duty nursing; assistive technology; environmental modifications; and transition services.

1. The services covered in this waiver shall be appropriate and medically necessary to maintain the individual in the community in order to prevent institutionalization and shall be cost effective in the aggregate as compared to the alternative institutional placement.

2. CCC Plus Waiver services shall not be authorized if another entity is required to provide the services (e.g., schools, insurance). Waiver services shall not duplicate services available through other programs or funding streams.

3. An individual receiving CCC Plus Waiver services who is also getting hospice care may receive Medicaid-covered personal care (agency-directed and consumer-directed), respite care (agency-directed and consumer-directed), services facilitation, private duty nursing, adult day health care, transition services, and PERS services, regardless of whether the hospice provider receives reimbursement from Medicare or Medicaid for the services covered under the hospice benefit.

4. Agency-directed and consumer-directed personal care services and respite care services shall be subject to the electronic visit verification requirements set out in 12VAC30-60-65.

B. Disenrollment from consumer-directed services. In disenrollment situations, the waiver individual shall be offered agency-directed personal care and respite services from a provider of the waiver individual's choice.

1. A waiver individual may be found to be ineligible for CD services by either the LTSS screening team, DMAS, its designated agent, or the services facilitator. An individual may not begin or continue to receive CD services if there are circumstances where the waiver individual's health, safety, or welfare cannot be assured, including:

a. It is determined that the waiver individual cannot complete the duties of the EOR and no one else is able to assume this role;

b. The waiver individual cannot ensure his own health, safety, or welfare or develop an emergency backup plan that will ensure his health, safety, or welfare; or

c. The waiver individual has medication or skilled nursing needs or medical or behavioral conditions that cannot be met through CD services or other services.

2. The waiver individual may be involuntarily disenrolled from consumer direction if the individual or the EOR, as appropriate, is consistently unable to retain or manage the attendant as may be demonstrated by, but not necessarily limited to, a pattern of serious discrepancies with the attendant's work shift entries or noncompliance with CD EOR requirements.

3. In situations where either (i) the waiver individual's health, safety, or welfare cannot be assured or (ii) attendant work shift entry discrepancies are known, the services facilitator shall assist as requested with the waiver individual's transfer to agency-directed services as follows:

a. Verify that essential training has been provided to the waiver individual or EOR;

b. Document, in the waiver individual's record, the conditions creating the necessity for the involuntary disenrollment and actions taken by the services facilitator;

c. Discuss with the waiver individual or the EOR, as appropriate, the agency-directed option that is available and the actions needed to arrange for such services and offer choice of potential providers; and

d. Provide written notice to the waiver individual of the right to appeal such involuntary termination of consumer direction. Such notice shall be given at least 10 calendar days prior to the effective date of this change. In cases when the individual's or the provider personnel's safety may be in jeopardy, the 10 calendar days' notice shall not apply.

C. Adult day health care (ADHC) services. ADHC services shall only be offered to waiver individuals who meet LTSS screening criteria as established in 12VAC30-60-303 and 12VAC30-60-313 and for whom ADHC services shall be an appropriate and medically necessary alternative to institutional care. ADHC services may be offered to individuals in a VDSS-licensed adult day care center (ADCC) congregate setting. ADHC may be offered either as the sole home and community-based waiver service or in conjunction with personal care (either agency-directed or consumer-directed), respite care (either agency-directed or consumer-directed), or PERS. A multi-disciplinary approach to developing, implementing, and evaluating each waiver individual's POC shall be essential to quality ADHC services.

1. ADHC services shall be designed to prevent institutionalization by providing waiver individuals with health care services, maintenance of the individual's physical and mental conditions, and coordination of rehabilitation services in a congregate daytime setting and shall be tailored to each individual's unique needs. The minimum range of services that shall be made available to every waiver individual shall be: assistance with ADLs, nursing services, coordination of rehabilitation services, nutrition, social services, recreation, and socialization services.

a. Assistance with ADLs shall include supervision of the waiver individual and assistance with management of the individual's POC.

b. Nursing services shall include the periodic evaluation, at least every 90 days, of the waiver individual's nursing needs; provision of indicated nursing care and treatment; responsibility for monitoring, recording, and administering prescribed medications; supervision of the waiver individual in self-administered medication; support of families in their home care efforts for the waiver individuals through education and counseling; and helping families identify and appropriately utilize health care resources. Periodic evaluations may occur more frequently than every 90 days if indicated by the individual's changing condition. Nursing services shall also include the general supervision of provider staff, who are certified through the Board of Nursing, in medication management and administering medications.

c. Coordination and implementation of rehabilitation services to ensure the waiver individual receives all rehabilitative services deemed necessary to improve or maintain independent functioning, to include physical therapy, occupational therapy, and speech therapy.

d. Nutrition services shall be provided to include one or more meals per day that meets the daily nutritional requirements pursuant to 22VAC40-61-360. Special diets and nutrition counseling shall be provided as required or requested by the waiver individual.

e. Recreation and social activities shall be provided that are suited to the needs of the waiver individuals and shall be designed to encourage physical exercise, prevent physical and mental deterioration, and stimulate social interaction.

f. ADHC coordination shall involve implementing the waiver individuals' POCs, updating such plans, recording 30-day progress notes, and reviewing the waiver individuals' daily logs each week.

2. Limits on covered ADHC services.

a. A day of ADHC services shall be defined as a minimum of six hours.

b. ADHCs that do not employ professional nursing staff on site shall not be permitted to admit waiver individuals who require skilled nursing care to their centers. Examples of skilled nursing care may include: (i) tube feedings; (ii) Foley catheter irrigations; (iii) sterile dressing changing; or (iv) any other procedures that require sterile technique. The ADCC shall not permit its aide employees to perform skilled nursing procedures.

c. At any time that the center is no longer able to provide reliable, continuous care to any of the center's waiver individuals for the number of hours per day or days per week as contained in the individuals' POCs, the center shall contact the waiver individuals, family, caregivers, or MCO care coordinators, as appropriate, to initiate other care arrangements for these individuals. The center may either subcontract with another ADCC or may transfer the waiver individual to another ADCC. The center may discharge waiver individuals from the center's services but not from the waiver. Written notice of discharge shall be provided, with the specific reason or reasons for discharge, at least 10 calendar days prior to the effective date of the discharge. In cases when the individual's or the center personnel's safety may be in jeopardy, the 10 calendar days' notice shall not apply.

d. ADHC services shall not be provided, for the purpose of Medicaid reimbursement, to individuals who reside in nursing facilities, intermediate care facilities for individuals with intellectual disabilities, hospitals, assisted living facilities that are licensed by VDSS, or group homes that are licensed by DBHDS.

D. Agency-directed personal care services. Agency-directed personal care services shall be offered to persons who meet the LTSS screening criteria at 12VAC30-60-303 and 12VAC30-60-313 and for whom it shall be an appropriate alternative to institutional care. Agency-directed personal care services shall be comprised of hands-on care of either a supportive or health-related nature and shall include assistance with ADLs, access to the community, assistance with medications in accordance with VDH licensing requirements or other medical needs, supervision, and the monitoring of health status and physical condition. Where the individual requires assistance with ADLs, and when specified in the POC, such supportive services may include assistance with IADLs. This service shall not include skilled nursing services with the exception of skilled nursing tasks (e.g., catheterization) that may be delegated pursuant to Part V (18VAC90-19-240 through 18VAC90-19-280) of 18VAC90-19. Agency-directed personal care services may be provided in a home or community setting to enable an individual to maintain the health status and functional skills necessary to live in the community or participate in community activities. Personal care may be offered either as the sole home and community-based waiver service or in conjunction with adult day health care, respite care (agency-directed or consumer-directed), or PERS. The provider shall document, in the individual's medical record, the waiver individual's choice of the agency-directed model.

1. Criteria. In order to qualify for this service, the waiver individual shall have met the LOC criteria as set out in 12VAC30-60-303 and 12VAC30-60-313 as documented on the UAI assessment form, and for whom it shall be an appropriate alternative to institutional care.

a. A waiver individual may receive both CD and agency-directed personal care services if the individual meets the criteria. Hours received by the individual who is receiving both CD and agency-directed services shall not exceed the total number of hours that would be needed if the waiver individual were receiving personal care services through a single delivery model.

b. CD and agency-directed services shall not be simultaneously provided but may be provided sequentially or alternately from each other.

c. The individual, family, or caregiver shall have a backup plan or caregiver for the provision of services in the event the agency is unable to provide an aide.

2. Limits on covered agency-directed personal care services.

a. DMAS shall not duplicate services that are required as a reasonable accommodation as a part of the Americans with Disabilities Act (42 USC §§ 12131 through 12165) or the Rehabilitation Act of 1973 (29 USC § 794).

b. DMAS or its contractor shall reimburse for services delivered, consistent with the approved POC, for personal care that the personal care aide provides to the waiver individual to assist while at work or postsecondary school or both.

(1) DMAS or the designated service authorization contractor shall review the waiver individual's needs and the complexity of the disability, as applicable, when determining the services that are provided to the individual in the workplace or postsecondary school or both.

(2) DMAS shall not pay for the personal care aide to assist the waiver individual with any functions or tasks related to the individual completing a job or postsecondary school functions or for supervision time during either work or postsecondary school or both.

c. Supervision services shall be authorized to ensure the health, safety, or welfare of the waiver individual who cannot be left alone at any time or is unable to call for help in case of an emergency, and when there is no competent adult in the home able to call for help in case of an emergency.

d. There shall be a maximum limit of eight hours per day for supervision services. Supervision services shall be documented in the POC as needed by the individual.

e. Agency-directed personal care services shall be limited to 56 hours of services per week for 52 weeks per year. Exceptions may be granted based on criteria set forth in 12VAC30-120-927.

f. Electronic visit verification requirements set out in 12VAC30-60-65 shall apply to these agency-directed respite care services.

g. Due to the complex medical needs of waiver individuals requiring PDN services and the need for 24-hour supervision, the trained primary caregiver shall be present in the home and shall render the required skilled services during the entire time that the aide is providing unskilled care.

E. Agency-directed respite care services. Agency-directed respite care services shall be offered to waiver individuals who meet the LTSS screening criteria at 12VAC30-60-303 and 12VAC30-60-313 and for whom it shall be an appropriate alternative to institutional care. Agency-directed respite care services may be either skilled respite or unskilled care and shall be comprised of hands-on care of either a supportive or health-related nature and may include assistance with ADLs, access to the community, assistance with medications in accordance with VDH licensing requirements or other medical needs, supervision, and monitoring health status and physical condition. Skilled respite care shall include skilled nursing care ordered on the physician-certified POC.

1. Respite care shall only be offered to individuals who have an unpaid primary caregiver who requires temporary relief to avoid institutionalization of the waiver individual. Respite care services may be provided in the individual's home or other community settings. Respite shall also be provided in children's residential facilities in accordance with 12VAC30-120-925.

2. When the individual requires assistance with ADLs, and where such assistance is specified in the waiver individual's POC, such supportive services may also include assistance with IADLs.

3. Unskilled respite service shall not include skilled nursing services with the exception of skilled nursing tasks (e.g., catheterization) that may be delegated pursuant to Part V (18VAC90-19-240 through 18VAC90-19-280) of 18VAC90-19.

4. Skilled respite care services.

a. This service shall be provided by skilled nursing staff licensed to practice in the Commonwealth under the direct supervision of a licensed, certified, or accredited home health agency with which DMAS has a provider agreement to provide PDN. Direct supervision means that the supervising RN is immediately accessible by telephone to the RN, LPN, or personal care aide who is delivering waiver-covered services to individuals.

b. Skilled respite care services shall be comprised of both skilled and hands-on care of either a supportive or health-related nature and may include all skilled nursing care as ordered on the physician-certified POC, assistance with ADLs or IADLs, administration of medications or other medical needs, and monitoring of the health status and physical condition of individuals.

c. When skilled respite services are offered in conjunction with PDN, the same individual record may be used with a separate section for skilled respite services documentation. This documentation must be clearly labeled as distinct from PDN services.

d. Individuals who reside in the same house shall be permitted to share skilled respite care service providers. The same limits on this service in the congregate setting (480 hours per calendar year per household) shall apply regardless of the type of waiver.

5. Limits on service.

a. The unit of service shall be one hour. Respite care services shall be limited to 480 hours per individual per calendar year, to be service authorized. No additional respite hours beyond the maximum limit shall be approved for payment for individuals, even those who change waiver programs. Additionally, individuals who are receiving respite services in this waiver through both the agency-directed and CD models shall not exceed 480 hours per calendar year combined.

b. If agency-directed respite care service is the only service received by the waiver individual, it must be received at least as often as every 30 days. If this service is not required at this minimal level of frequency, then the provider or MCO shall notify the local department of social services for its redetermination of eligibility for the waiver individual.

c. The individual, family, or caregiver shall have a backup plan or caregiver for the provision of services in the event the agency is unable to provide an aide.

d. Electronic visit verification requirements set out in 12VAC30-60-65 shall apply to these agency-directed respite care services.

F. Services facilitation for consumer-directed services. Consumer-directed personal care and respite care services shall only be offered to waiver individuals who meet the LTSS screening criteria at 12VAC30-60-303 and 12VAC30-60-313 and for whom there shall be appropriate alternatives to institutional care.

1. Individuals who choose CD services shall receive support from a DMAS-enrolled services facilitator or a provider designated by the managed care organization as required in conjunction with CD services. The services facilitator shall document the waiver individual's choice of the CD model and whether there is a need for another person to serve as the EOR on behalf of the individual. The services facilitator shall be responsible for assessing the waiver individual's particular needs for a requested CD service, assisting in the development of the POC, providing training to the EOR on the EOR's responsibilities as an employer, and for providing ongoing support of the CD services.

2. Individuals who are eligible for CD services shall have an EOR who has the capability to hire, to train, and to fire the personal care attendant and supervise the attendant's performance, including approving the attendant's work shift entries.

a. If a waiver individual is unwilling or unable to direct the individual's own care or is younger than 18 years of age, family, a caregiver, or a designated person shall serve as the EOR on behalf of the waiver individual in order to perform these supervisory and work shift entry approval functions.

b. Specific employer duties shall include checking references of personal care attendants and determining that personal care attendants meet qualifications.

3. The individual, family, or caregiver shall have a backup plan or caregiver for the provision of services in case the attendant does not show up for work as scheduled or terminates employment without prior notice.

4. The services facilitator shall not be the waiver individual, a CD attendant, a provider of other Medicaid-covered services, the spouse of the waiver individual, the natural, adoptive, step, or foster parent or other legal guardian of the waiver individual who is a minor, or the EOR who is employing the CD attendant.

5. DMAS or the MCO shall either provide for fiscal/employer agent services or contract for the services of a fiscal/employer agent for CD services. The fiscal/employer agent shall be reimbursed by DMAS or the DMAS contractor to perform certain tasks as an agent for the EOR. The fiscal/employer agent shall handle responsibilities for the waiver individual, including payroll, employment taxes, and background checks for attendants. The fiscal/employer agent shall seek and obtain all necessary authorizations and approvals of the Internal Revenue Service in order to fulfill all of these duties.

G. Consumer-directed personal care services. CD personal care services shall be comprised of hands-on care of either a supportive or health-related nature and shall include assistance with ADLs, access to the community, monitoring of self-administered medications or other medical needs, supervision, and the monitoring of health status and physical condition. Where the waiver individual requires assistance with ADLs, and when specified in the POC, such supportive services may include assistance with IADLs. This service shall not include skilled nursing services with the exception of skilled nursing tasks (e.g., catheterization) that may be delegated pursuant to Part V (18VAC90-19-240 through 18VAC90-19-280) of 18VAC90-19 and as permitted by Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia. CD personal care services may be provided in a home or community setting to enable an individual to maintain the health status and functional skills necessary to live in the community or participate in community activities. Personal care may be offered either as the sole home and community-based waiver service or in conjunction with adult day health care, respite care (agency-directed or consumer-directed), or PERS.

1. In order to qualify for this service, the waiver individual shall have met the LOC criteria as set out in 12VAC30-60-303 and 12VAC30-60-313 as documented on the UAI assessment instrument, and for whom it shall be an appropriate alternative to institutional care.

a. A waiver individual may receive both CD and agency-directed personal care services if the individual meets the criteria. Hours received by the waiver individual who is receiving both CD and agency-directed services shall not exceed the total number of hours that would be otherwise authorized had the individual chosen to receive personal care services through a single delivery model.

b. CD and agency-directed services shall not be simultaneously provided but may be provided sequentially or alternately from each other.

2. Limits on covered CD personal care services.

a. DMAS shall not duplicate services that are required as a reasonable accommodation as a part of the Americans with Disabilities Act (42 USC §§ 12131 through 12165) or the Rehabilitation Act of 1973 (29 USC § 794).

b. There shall be a limit of eight hours per day for supervision services included in the POC. Supervision services shall be authorized to ensure the health, safety, or welfare of the waiver individual who cannot be left alone at any time or is unable to call for help in case of an emergency, and when there is no other competent adult able to call for help in case of an emergency.

c. Consumer-directed personal care services shall be limited to 56 hours of services per week for 52 weeks per year. Exceptions may be granted based on criteria set forth in 12VAC30-120-927.

d. Electronic visit verification requirements as set out in 12VAC30-60-65 shall apply to these CD personal care services.

e. Due to the complex medical needs of waiver individuals requiring PDN services and the need for 24-hour supervision, the trained primary caregiver shall be present in the home and shall render the required skilled services during the entire time that the attendant is providing unskilled care.

3. CD personal care services at work or school shall be limited as follows:

a. DMAS or its contractor shall reimburse for services delivered, consistent with the approved POC, for CD personal care that the attendant provides to the waiver individual to assist while at work or postsecondary school or both.

b. DMAS or the designated service authorization contractor shall review the waiver individual's needs and the complexity of the disability, as applicable, when determining the services that will be provided to the individual in the workplace or postsecondary school or both.

c. DMAS shall not pay for the personal care attendant to assist the waiver individual with any functions or tasks related to the individual completing a job or postsecondary school functions or for supervision time during work or postsecondary school or both.

H. Consumer-directed respite care services. CD respite care services are unskilled care and shall be comprised of hands-on care of either a supportive or health-related nature and may include assistance with ADLs, access to the community, monitoring of self-administration of medications or other medical needs, supervision, monitoring health status and physical condition, and personal care services in a work environment.

1. In order to qualify for this service, the waiver individual shall have met the LOC criteria as set out in 12VAC30-60-303 and 12VAC30-60-313 as documented on the UAI form, and for whom it shall be an appropriate alternative to institutional care.

2. CD respite care services shall only be offered to individuals who have an unpaid primary caregiver who requires temporary relief to avoid institutionalization of the waiver individual. This service shall be provided in the waiver individual's home or other community settings.

3. When the waiver individual requires assistance with ADLs, and where such assistance is specified in the individual's POC, such supportive services may also include assistance with IADLs.

4. Electronic visit verification requirements as set out in 12VAC30-60-65 shall apply to these CD respite care services.

5. Limits on covered CD respite care services.

a. The unit of service shall be one hour. Respite care services shall be limited to 480 hours per waiver individual per calendar year. If a waiver individual changes waiver programs, this same maximum number of respite hours shall apply. No additional respite hours beyond the 480 maximum limit shall be approved for payment. Individuals who are receiving respite care services in this waiver through both the agency-directed and CD models shall not exceed 480 hours per calendar year combined.

b. CD respite care services shall not include skilled nursing services with the exception of skilled nursing tasks (e.g., catheterization) that may be delegated pursuant to Part V (18VAC90-19-240 through 18VAC90-19-280) of 18VAC90-19 and as permitted by Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia).

c. If consumer-directed respite care service is the only service received by the waiver individual, it shall be received at least as often as every 30 days. If this service is not required at this minimal level of frequency, then the services facilitator or MCO shall refer the waiver individual to the local department of social services for its redetermination of Medicaid eligibility for the waiver individual.

I. Personal emergency response system (PERS).

1. Service description. PERS is a service that monitors the individual's safety in the home and provides access to emergency assistance for medical or environmental emergencies through the provision of a two-way voice communication system that dials a 24-hour response or monitoring center upon activation and via the individual's home telephone line or system. PERS may also include medication monitoring devices.

a. PERS shall be authorized only when there is no other competent adult in the home who is available to call for help in an emergency or when the individual's health, safety, and welfare cannot be ensured.

b. The use of PERS equipment shall not relieve the primary or backup caregiver of the caregiver's responsibilities.

c. Service units and service limitations.

(1) PERS shall be limited to waiver individuals who are ages 14 years and older who also either live alone or are alone for significant parts of the day and who have no regular caregiver for extended periods of time. PERS shall only be provided in conjunction with receipt of personal care services (either agency-directed or consumer-directed), respite services (either agency-directed or consumer-directed), or adult day health care. A waiver individual shall not receive PERS if the individual has a cognitive impairment as defined in 12VAC30-120-900.

(2) A unit of service shall include administrative costs, time, labor, and supplies associated with the installation, maintenance, monitoring, and adjustments of the PERS. A unit of service shall be the one-month rental price set by DMAS in its fee schedule. The one-time installation of the unit shall include installation, account activation, individual and family or caregiver instruction, and subsequent removal of PERS equipment when it is no longer needed.

(3) PERS services shall be capable of being activated by a remote wireless device and shall be connected to the waiver individual's telephone line or system. The PERS console unit must provide hands-free voice-to-voice communication with the response center. The activating device must be (i) waterproof, (ii) able to automatically transmit to the response center an activator low battery alert signal prior to the battery losing power, (iii) able to be worn by the waiver individual, and (iv) automatically reset by the response center after each activation, thereby ensuring that subsequent signals can be transmitted without requiring manual resetting by the waiver individual.

(4) All PERS equipment shall be approved by the Federal Communications Commission and meet the Underwriters' Laboratories, Inc. (UL) safety standard.

(5) Medication monitoring units shall be physician ordered. In order to be approved to receive the medication monitoring service, a waiver individual shall also receive PERS services. Physician orders shall be maintained in the waiver individual's record. In cases where the medical monitoring unit must be filled by the provider, the person who is filling the unit shall be either an RN or an LPN. The units may be filled as frequently as a minimum of every 14 days. There must be documentation of this action in the waiver individual's record.

J. Transition services. Transition services, as defined at 12VAC30-120-2010, provide for individuals to move from institutional placements or licensed or certified provider-operated living arrangements to private homes or other qualified settings. The individual's transition from an institution to the community shall be coordinated by the facility's discharge planning team. The discharge planner shall ensure that CCC Plus Waiver eligibility criteria shall be met.

1. Transition services shall be authorized by DMAS or its designated agent in order for reimbursement to occur.

2. To qualify for the service, the waiver individual shall be discharged after 90 consecutive days of residence from an institution, intermediate care facility for individuals with intellectual disabilities, institution for mental disease, or psychiatric residential treatment facility.

3. Transition services shall be provided in conjunction with personal care (agency-directed or consumer-directed), respite care (agency-directed or consumer-directed), private duty nursing, or adult day health care services.

4. Transition services may be provided by DMAS enrolled area agencies on aging, centers for independent living, and local departments of social services.

K. Assistive technology (AT).

1. Assistive technology (AT) shall be portable and shall be authorized per calendar year. AT services are the specialized medical equipment and supplies, including those devices, controls, or appliances, specified in the individual's plan of care, but that are not available under the State Plan for Medical Assistance, that enable a waiver individual to increase the individual's ability to perform ADLs or IADLs or to perceive, control, or communicate with the environment in which the individual lives.

2. In order to qualify for these services, the individual shall have a demonstrated need for specialized medical equipment and supplies for remedial or direct medical benefit primarily in an individual's primary home, primary vehicle used by the individual, community activity setting, or day program to specifically serve to improve the individual's personal functioning. This shall encompass those items not otherwise covered under the State Plan for Medical Assistance. AT shall be covered in the least expensive manner.

3. AT services shall be available for a waiver individual who has a demonstrated need for equipment for remedial or direct medical benefit. This service includes ancillary supplies and equipment necessary for the proper functioning of such items.

4. Service units and service limitations.

a. The cost for AT shall not be carried over from one calendar year to the next. Each item must be service authorized by either DMAS or the DMAS-designated service authorization contractor for each calendar year.

b. The maximum funded expenditure per individual for all AT covered procedure codes (combined total of AT items and labor related to these items) shall be $5,000 per calendar year for an individual regardless of waiver, or regardless of whether the individual changes waiver programs, for which AT is approved. The service unit shall always be one, for the total cost of all AT being requested for a specific timeframe.

c. AT may be provided in the individual's home or community setting.

d. AT shall not be approved for purposes of convenience of the caregiver or provider or restraint of the individual, recreation or leisure, educational purposes, or diversion activities.

e. AT shall be carried out in the least expensive manner possible to achieve the goal required for the individual's health, safety, and welfare. AT shall be reimbursed in a manner that is reasonable and customary not to exceed the provider's usual and customary charges to the general public.

f. An independent, professional consultation shall be obtained from a qualified professional who is knowledgeable of that item for each AT request prior to approval by the service authorization contractor or managed care organization and may include training on such AT by the qualified professional. The consultation shall not be performed by the provider of AT to the individual.

g. All AT shall be authorized by DMAS, the designated service authorization contractor, or managed care organization prior to billing or providing services to the individual.

h. Items that are reasonable accommodation requirements of the Americans with Disabilities Act, the Virginians with Disabilities Act (§ 51.5-1 et seq. of the Code of Virginia), or the Rehabilitation Act (20 USC § 794) or are required to be provided through other funding sources shall be excluded from Medicaid coverage. DMAS shall not duplicate services that are required as a reasonable accommodation as a part of the Americans with Disabilities Act (42 USC §§ 12131 through 12165), Virginians with Disabilities Act (§ 51.5-1 et seq. of the Code of Virginia), or the Rehabilitation Act of 1973 (29 USC § 794).

i. AT services or equipment shall not be rented but shall be purchased.

j. Shipping, freight, or delivery charges shall not be billable to DMAS or the waiver individual, as such charges are considered noncovered items.

(1) All products shall be delivered, demonstrated, and installed and in working order prior to submitting any claim for them to Medicaid.

(2) The date of service on the claim shall be within the service authorization approval dates, which may be prior to the delivery date as long as the initiation of services commenced during the approved dates.

(3) The service authorization shall not be modified to accommodate delays in product deliveries. In such situations, the provider must seek a new service authorization.

(4) When two or more waiver individuals live in the same home or congregate living arrangement, the AT shall be shared to the extent practicable consistent with the type of AT and the needs of the individuals as documented in their POCs. There shall be no duplication of AT in the same house when such product can be used for a communal purpose.

k. Assistive technology shall not be available to individuals younger than 21 years of age through the CCC Plus Waiver. Assistive technology for individuals younger than 21 shall be accessed through the EPSDT benefit.

l. AT exclusions.

(1) Medicaid shall not reimburse for any AT devices or services that may have been rendered prior to authorization from DMAS or the designated service authorization contractor.

(2) Providers that supply AT for the waiver individual may not perform assessments, consultations, or write specifications for that individual. Any request for a change in cost (either an increase or a decrease) requires justification and supporting documentation of medical need and service authorization by DMAS or the designated service authorization contractor. The vendor shall receive a copy of the professional evaluation in order to purchase the items recommended by the professional. If a change is necessary, the vendor shall notify the assessor to ensure the changed items meet the individual's needs.

(3) All equipment or supplies already covered by a service provided for in the State Plan shall not be purchased under the waiver as AT. Such examples include:

(a) Specialized medical equipment, durable or nondurable medical equipment, ancillary equipment, and supplies necessary for life support;

(b) Adaptive devices, appliances, and controls that enable an individual to be more independent in areas of personal care and ADLs or IADLs; and

(c) Equipment and devices that enable an individual to communicate more effectively.

L. Environmental modifications (EM).

1. Environmental modifications (EM) shall consist of adaptations documented in the waiver individual's POC and may include the installation of nonportable ramps and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electrical and plumbing systems that are necessary to accommodate the medical equipment and supplies that are necessary for the health, safety, and welfare of the waiver individual. Excluded are those adaptations or improvements to the home that are of general utility and are not of direct medical or remedial benefit to the individual, such as carpeting, flooring, roof repairs, central air conditioning, or decks. Adaptations that add to the total square footage of the home shall be excluded from this benefit, except when necessary to complete an authorized adaptation, as determined by DMAS or its designated agent. All services shall be provided in the individual's primary home in accordance with applicable state or local building codes. All modifications shall be prior authorized by the service authorization contractor or managed care organization. Modifications may only be made to a vehicle if it is the primary vehicle being used by the waiver individual. This service does not include the purchase or lease of vehicles. This service shall not include general repairs to a residence or vehicle.

2. In order to qualify for these services, the waiver individual shall have a demonstrated need for modifications of a remedial or direct medical benefit offered in the individual's primary home or primary vehicle to ensure the individual's health, welfare, or safety or specifically to improve the individual's personal functioning. Modifications may include a generator for a waiver individual who is dependent on mechanical ventilation for 24 hours a day and when the generator is used to support the medical equipment and supplies necessary for the individual's welfare. This service shall encompass those items not otherwise covered in the State Plan for Medical Assistance or through another program. EM shall be covered in the least expensive manner.

3. Service units and service limitations.

a. The maximum funded expenditure per individual for all EM covered procedure codes (combined total of EM items and labor related to these items) shall be $5,000 per calendar year for an individual regardless of waiver, or regardless of whether the individual changes waiver programs, for which EM is approved. Unexpended portions of this maximum amount shall not be accumulated across one or more years to be expended in a later year. The service unit shall always be one, for the total cost of all EM being requested for a specific timeframe.

b. All EM shall be authorized by DMAS or the DMAS-designated service authorization contractor prior to billing or providing services to the individual.

c. Modifications shall not be used to bring a substandard dwelling up to minimum habitation standards.

d. EM shall not be approved for purposes of convenience of the caregiver or provider or restraint of the waiver individual.

e. Only the actual cost of material and labor is reimbursed. There shall be no additional markup.

f. EM shall be carried out in the least expensive manner possible to achieve the goal required for the individual's health, safety, and welfare.

g. All services shall be provided in the individual's primary residence in accordance with applicable state or local building codes and appropriate permits or building inspections, which shall be provided to DMAS or the DMAS contractor.

h. Proposed modifications that are to be made to rental properties shall have prior written approval of the property's owner. Modifications to rental properties shall only be valid if it is an independently operated rental facility with no direct or indirect ties to any other Medicaid service provider.

i. Modifications may be made to a vehicle if it is the primary vehicle used by the individual. This service shall not include the purchase of, lease of, or the general repair of vehicles. Repairs of modifications that have been reimbursed by DMAS shall be covered.

j. The EM provider shall ensure that all work and products are delivered, installed, and in good working order prior to seeking reimbursement from DMAS. The date of service on this provider's claim shall be within the service authorization approval dates, which may be prior to the completion date as long as the work commenced during the approval dates. The service authorization shall not be modified to accommodate installation delays. All requests for cost changes (either increases or decreases) shall be submitted to DMAS or the DMAS-designated service authorization contractor for revision to the previously issued service authorization and shall include justification and supporting documentation of medical needs.

k. DMAS shall not duplicate services that are required as a reasonable accommodation as a part of the Americans with Disabilities Act (42 USC §§ 12131 through 12165), the Virginians with Disabilities Act (§ 51.5-1 et seq. of the Code of Virginia), or the Rehabilitation Act of 1973 (29 USC § 794).

4. EM exclusions.

a. There shall be no duplication of previous EM services within the same residence such as multiple nonportable wheelchair ramps or previous modifications to the same room.

b. Adaptations or improvements to the primary home that shall be excluded are of general utility and are not of direct medical or remedial benefit to the waiver individual, such as, but not limited to, carpeting; flooring; roof repairs; central air conditioning or heating; general maintenance and repairs to a home; additions or maintenance of decks or fences; maintenance, replacement, or addition of sidewalks, driveways, or carports; or adaptations that only increase the total square footage of the home.

c. EM shall not be covered by Medicaid for general leisure or diversion items, items that are recreational in nature, items for educational purposes, or items that may be used as an outlet for adaptive or maladaptive behavioral issues. Such noncovered items may include swing sets, playhouses, climbing walls, trampolines, protective matting or ground cover, sporting equipment, hot tubs, or exercise equipment, such as special bicycles or tricycles.

d. EM shall not be covered by Medicaid if payment for such modifications can be made through the Fair Housing Act (42 USC § 3601 et seq.), the Virginia Fair Housing Law (§ 36-96.1 et seq. of the Code of Virginia) or the Americans with Disabilities Act (42 USC § 12101 et seq.).

e. EM shall not include the costs of removal or disposal, or any other costs, of previously installed modifications, whether paid for by DMAS or any other source.

f. Providers who supply EM to a waiver individual shall not perform assessments, consultations, or write EM specifications for such individuals .

g. EM shall not cover payment for modifications or items that can be made through other Medicaid services, such as durable medical equipment.

M. Private duty nursing. PDN for a single individual and individuals residing in the same home, as defined in 12VAC30-120-900, shall be provided for individuals who have serious medical conditions or complex health care needs. To receive this service, an individual must require specific skilled and continuous nursing care on a regularly scheduled or intermittent basis performed by an RN or an LPN. Once waiver eligibility has been determined by the LTSS screening team and a determination that the individual requires ongoing skilled nursing care has been made, then the PDN hours shall be authorized by DMAS or the DMAS-designated service authorization contractor.

1. PDN services shall be rendered according to a POC authorized by DMAS or the DMAS-designated service authorization contractor and shall have been certified by a physician as medically necessary to enable the individual to remain at home.

2. No reimbursement shall be provided by DMAS for either RN or LPN services without signed physician orders that specifically identify skilled nursing tasks to be performed for the individual.

3. Limits placed on the amount of PDN that will be approved for reimbursement shall be consistent with the individual's support needs and medical necessity but shall not exceed 112 hours per week. The maximum PDN hours authorized per week for individuals shall be based on their technology and documented medical necessity justification.

4. For individuals, whether living separately or in a congregate setting, PDN shall be reimbursed up to a maximum 112 hours per week (Sunday through Saturday) per waiver individual living in the household.

5. The individual shall be determined to need a medical device and ongoing skilled nursing care when such individual meets Category A or all eight criteria in Category B:

a. Category A. Individuals who depend on mechanical ventilators; or

b. Category B. Individuals who have a complex tracheostomy as defined by:

(1) Tracheostomy with the potential for weaning off of it, or documentation of attempts to wean, with subsequent inability to wean;

(2) Nebulizer treatments ordered at least four times a day or nebulizer treatments followed by chest physiotherapy provided by a nurse or respiratory therapist at least four times a day;

(3) Pulse oximetry monitoring at least every shift due to unstable oxygen saturation levels;

(4) Respiratory assessment and documentation every shift by a licensed respiratory therapist or nurse;

(5) Oxygen therapy with documented usage under a physician's order;

(6) Daily tracheostomy care;

(7) Tracheostomy suctioning under a physician's order; and

(8) At risk of requiring subsequent mechanical ventilation.

6. PDN shall not be available to individuals younger than 21 years of age as a waiver service. PDN for individuals younger than 21 shall be accessed through the EPSDT benefit.

7. PDN services may include consultation and training for the primary caregiver.

8. The provider shall be responsible for notifying the LDSS, the service authorization contractor, and the managed care organization should the primary residence of the individual be changed, should the individual be hospitalized, should the individual die, or should the individual be absent from the Commonwealth for 48 hours or more.

9. Exclusions from DMAS coverage of PDN:

a. PDN hours shall not be reimbursed while the individual is receiving emergency care or during emergency transport of the individual to emergency care facilities. The RN or LPN shall not transport the waiver individual to emergency care facilities.

b. PDN services may be ordered but shall not be provided simultaneously with skilled respite care or personal care services. These services may be provided sequentially or alternately from each other.

c. Providers shall not bill prior to receiving the physician's dated signature on the individual's POC for services provided and DMAS or DMAS-designated service authorization contractor's authorization or determination of PDN hours.

d. Time spent transporting the waiver individual shall not be reimbursed by DMAS.

e. DMAS shall not reimburse for PDN services through the CCC Plus Waiver and PDN services through the EPSDT benefit at the same time.

10. Congregate PDN.

a. If more than one waiver individual resides in the home, the same waiver provider shall be chosen to provide all PDN services for all waiver individuals in the home.

b. Only one nurse shall be authorized to care for no more than two waiver individuals in such arrangements. In instances when three waiver individuals share a home, nursing ratios shall be determined by DMAS or its designated agent based on the needs of all the individuals who are living together. These congregate PDN hours shall be at the same scheduled shifts.

c. The unpaid primary caregiver shall be shared and shall be responsible for providing all care needs when a private duty nurse is not available.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 31, Issue 10, eff. February 12, 2015; amended, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-925. Respite coverage in children's residential facilities.

A. Individuals who have a diagnosis of intellectual disability (ID) or developmental disability (DD) shall be eligible to receive respite services in children's residential facilities that are licensed for respite services for children with ID or DD.

B. These respite services shall be covered consistent with the requirements of 12VAC30-120-924, 12VAC30-120-930, and 12VAC30-120-935, whichever is in effect at the time of service delivery with the following exceptions:

1. An assessment by the nurse supervisor shall be conducted at the onset of each use of respite in the children's residential facility;

2. Documentation of each utilization of respite in a children's residential facility will document the arrival and departure times of the individual instead of the arrival and departure times of each staff member; and

3. The nurse supervisor shall review the utilization of respite services in the children's residential facility. The nurse supervisor shall not be required to conduct the supervisory visit in the home of the waiver individual.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 28, Issue 6, eff. January 1, 2012; amended, Virginia Register Volume 31, Issue 10, eff. February 12, 2015; Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-927. Exception criteria for personal care services.

DMAS shall apply the following criteria to individuals who request approval of personal care hours in excess of the maximum allowed 56 hours per week. In order to qualify for personal care hours in excess of 56 hours per week, the waiver individual shall:

1. Presently have a minimum level of care of B (the waiver individual has a composite activities of daily living (ADL) score between seven and 12 and has a medical nursing need) or C (the waiver individual has a composite ADL score of nine or higher and has a skilled medical nursing need).

2. In addition to meeting the requirements set out in subdivision 1 of this section, the individual shall have at least one of the following:

a. Documentation of dependencies in all of the following activities of daily living: bathing, dressing, transferring, toileting, and eating or feeding, as defined by the current LTSS screening criteria (12VAC30-60-303) submitted to the service authorization contractor via DMAS-99;

b. Documentation of dependencies in both behavior and orientation as defined by the current LTSS screening criteria (12VAC30-60-303) submitted to the service authorization contractor via DMAS-99; or

c. Documentation from the local department of social services that the individual has an open case (as described in subdivisions 2 c (1) and 2 c (2) of this section) with either adult protective services (APS) or child protective services (CPS) and is therefore in need of additional services beyond the maximum allowed 56 hours per week. Documentation can be in the form of a phone log contact or any other documentation supplied (submitted to the service authorization contractor via attestation).

(1) For APS, an open case is defined as a substantiated APS case with a disposition of needs protective services and the adult accepts the needed services.

(2) For CPS, an open case is defined as being open to CPS investigation if it is both founded by the investigation and the completed family assessment documents the case with moderate or high risk.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 32, Issue 7, eff. December 30, 2015; amended, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-930. General requirements for home and community-based participating providers.

A. The following agency-directed services shall be provided through an agency that is either (i) licensed by VDH, (ii) certified by VDH under provisions of Title XVIII or Title XIX of the Social Security Act, or (iii) accredited either by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) or by the Community Health Accreditation Program (CHAP) established by the National League of Nursing for Medicaid participation: personal care, respite care, PDN, skilled respite care, and congregate PDN. The provider shall make available verification of its license, certification, or accreditation upon request.

B. Requests for participation shall be screened by DMAS or the designated DMAS contractor to determine whether the provider applicant meets the requirements for participation, as set forth in the provider agreement, and demonstrates the abilities to perform, at a minimum, the following activities:

1. Screen 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 United States Department of Health and Human Services Office of Inspector General List of Excluded Individuals or Entities (LEIE) website). Immediately report in writing to DMAS any exclusion information discovered to: DMAS, ATTN: Program Integrity/Exclusions, 600 East Broad Street, Suite 1300, Richmond, VA 23219, or email to providerexclusions@dmas.virginia.gov;

2. Immediately notify DMAS in writing of any change in the information that the provider previously submitted to DMAS;

3. Ensure freedom of choice to individuals in seeking services from any institution, pharmacy, practitioner, or other provider qualified and enrolled in Medicaid at the time of delivery to perform the service required, except for waiver individuals who are subject to the DMAS Client Medical Management program as set out in Part XIII of 12VAC30-130 or are enrolled in a Medicaid managed care organization;

4. Ensure the individual's freedom to refuse medical care, treatment, and services;

5. Accept referrals for services only when staff is available to initiate and perform such services on an ongoing basis;

6. Provide services and supplies to individuals in full compliance with Title VI (42 USC § 2000d et seq.) of the Civil Rights Act of 1964, which prohibits discrimination on the grounds of race, color, religion, or national origin; the Virginians with Disabilities Act (§ 51.5-1 et seq. of the Code of Virginia); § 504 of the Rehabilitation Act of 1973 (29 USC § 794), which prohibits discrimination on the basis of a disability; and the Americans with Disabilities Act of 1990 (42 USC § 12101 et seq.), which provides comprehensive civil rights protections to individuals with disabilities in the areas of employment, public accommodations, state and local government services, and telecommunications;

7. Provide services and supplies to individuals of the same quality and in the same mode of delivery as are provided to the general public;

8. Submit charges to DMAS, the MCO, or the DMAS-designated service authorization contractor for the provision of services and supplies to 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 DMAS payment methodology beginning with the individual's authorization date for the waiver services;

9. Use only DMAS-designated forms for service documentation, except when otherwise permitted. The provider shall not alter the DMAS forms in any manner without prior written approval from DMAS;

10. Use DMAS-designated billing forms for submission of charges;

11. Perform no type of direct marketing activities to Medicaid individuals;

12. Maintain and retain business and professional records sufficient to document fully and accurately the nature, scope, and details of the services provided.

a. In all instances of forms required to be in records, all documents shall have original notes, dates, and signatures. Copied, re-dated, and photocopied forms, notes and signatures are prohibited. Signatures shall not be dated prior to the last date of rendered services for the appropriate form being used.

b. In general, such records shall be retained for a period of at least six years from the last date of service or as provided by applicable federal and state laws, whichever period is longer. However, if an audit is initiated within the required retention period, the records shall be retained until the audit is completed and every exception resolved. Records of minors shall be kept for a period of at least six years after such minor has reached 18 years of age.

c. Policies regarding retention of records shall apply even if the provider discontinues operation. DMAS shall be notified in writing of the storage location and procedures for obtaining records for review should the need arise. The location, agent, or trustee shall be within the Commonwealth;

13. Furnish information on the request of and in the form requested to DMAS or its contractors, the Attorney General of Virginia or their authorized representatives, federal personnel, and the state Medicaid Fraud Control Unit. The Commonwealth's right of access to provider agencies and records shall survive any termination of the provider 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 recipients of Medicaid;

15. Pursuant to 42 CFR 431.300 et seq., § 32.1-325.3 of the Code of Virginia, and the Health Insurance Portability and Accountability Act (HIPAA), safeguard and hold confidential all information associated with an applicant or enrollee or individual that could disclose the identity of the applicant, enrollee, or individual. Access to information concerning the applicant, enrollee, or individual shall be restricted to persons or agency representatives who are subject to the standards of confidentiality that are consistent with that of the agency and any such access must be in accordance with the provisions found in 42 CFR 431.306 and 12VAC30-20-90;

16. When ownership of the provider changes, notify DMAS in writing at least 15 calendar days before the date of change;

17. Pursuant to §§ 63.2-100, 63.2-1509, and 63.2-1606 of the Code of Virginia, if a participating provider or the provider's staff knows or suspects that a home and community-based waiver services individual is being abused, neglected, or exploited, the party having knowledge or suspicion of the abuse, neglect, or exploitation shall report this immediately to the local department of social services adult or child protective services department as applicable or to the toll-free, 24-hour hotline as described on the local department of social services' website. Employers shall ensure and document that their staff is aware of this requirement;

a. The party having knowledge or suspicion of abuse, neglect, or exploitation shall also report this immediately to DMAS or its authorized contractor separately as a critical incident. The provider shall ensure that in such instances of suspected or known abuse, neglect, or exploitation that DMAS or its authorized contractor are informed after notifying adult or child protective services and will document the date and time of report.

b. If a participating provider or the provider's staff knows or suspects that a waiver individual has incurred a critical incident that does not include suspected or known abuse, neglect, or exploitation, the party having knowledge or suspicion of the critical incident shall report this immediately to DMAS or the DMAS-designated contractor. Employers shall ensure and document that their staff is aware of this requirement and maintain copies of all records of reported critical incidents in the individual's file.

18. In addition to compliance with the general conditions and requirements, adhere to the conditions of participation outlined in the provider's participation agreements, in the applicable DMAS provider manual, and in other DMAS laws, regulations, and policies. DMAS shall conduct ongoing monitoring of compliance with provider participation standards and DMAS policies. A provider's noncompliance with DMAS policies and procedures may result in a retraction of Medicaid payment or termination of the provider agreement, or both;

19. Meet minimum qualifications of staff.

a. For reasons of Medicaid individuals' safety and welfare, all employees shall have a satisfactory work record, as evidenced by at least two references from prior job experience, including no evidence of abuse, neglect, or exploitation of incapacitated or older adults or children. In instances of employees who have worked for only one employer, such employees shall be permitted to provide one appropriate employment reference and one appropriate personal reference including no evidence of abuse, neglect, or exploitation of incapacitated or older adults or children.

b. Pursuant to 42 CFR 441.302 and 42 CFR 441.352, within 30 calendar days of employment, the staff or volunteer shall obtain an original criminal record clearance with respect to convictions for offenses specified in § 19.2-392.02 of the Code of Virginia or an original criminal history record from the Central Criminal Records Exchange.

(1) DMAS shall not reimburse a provider for services provided by a staff member or volunteer who works in a position that involves direct contact with a waiver individual until an original criminal record clearance or original criminal history record has been received. DMAS shall reimburse services provided by such staff member or volunteer during only the first 30 calendar days of employment if the provider can produce documented evidence that such person worked only under the direct supervision of another staff member or volunteer for whom a background check was completed in accordance with the requirements of this section. If an original criminal record clearance or original criminal history record is not received within the first 30 calendar days of employment, DMAS shall not reimburse the provider for services provided by such employee on the 31st calendar day through the date on which the provider receives an original criminal record clearance or an original criminal history record.

(2) DMAS shall not reimburse a provider for services provided by a staff member or volunteer who has been convicted of any offense set forth in clause (i) of the definition of barrier crime in § 19.2-392.02 of the Code of Virginia unless all of the following conditions are met: (i) the offense was punishable as a misdemeanor; (ii) the staff member or volunteer has been convicted of only one such offense; (iii) the offense did not involve abuse or neglect; and (iv) at least five years have elapsed since the conviction.

c. The staff or volunteer shall provide the hiring facility with a sworn statement or affirmation disclosing any criminal convictions or any pending criminal charges, whether within or outside of the Commonwealth.

d. Provider staff and volunteers shall not be debarred, suspended, or otherwise excluded from participating in federal health care programs, as listed on the federal List of Excluded Individuals/Entities (LEIE) database at https://oig.hhs.gov.

e. Provider staff and volunteers who serve waiver individuals who are minor children shall be screened through the VDSS Child Protective Services (CPS) Central Registry. Provider staff and volunteers shall not be reimbursed for services provided to the waiver individual effective on the date and thereafter that the VDSS CPS Central Registry check confirms the provider's staff person or volunteer has a finding.

20. Comply with the electronic visit verification requirements set out in 12VAC30-60-65.

21. Providers shall comply with requirements for person-centered planning and home and community-based settings as described in 42 CFR 441.301. As part of the person-centered planning process, providers shall discuss the available services to the individual to meet the individual's needs and shall not perform services that are not identified or agreed upon in the person-centered plan.

C. DMAS shall terminate the provider's Medicaid provider agreement pursuant to § 32.1-325 of the Code of Virginia and as may be required for federal financial participation. A provider who has been convicted of a felony, or who has otherwise pled guilty to a felony, in Virginia or in any other of the 50 states, the District of Columbia, or the U.S. territories shall within 30 days of such conviction notify DMAS of this conviction and relinquish its provider agreement. Such provider agreement terminations, subject to applicable appeal rights, shall conform to § 32.1-325 D and E of the Code of Virginia and Part XII (12VAC30-20-500 et seq.) of 12VAC30-20.

D. Home and community-based waiver services providers shall meet the following standards:

1. Staffing, financial solvency, disclosure of ownership, and ensuring comparability of services requirements as specified in the applicable provider manual;

2. The ability to document and to maintain waiver individuals' case records in accordance with state and federal requirements;

3. Compliance with all applicable laws, regulations, and policies pertaining to CCC Plus Waiver services.

E. The waiver individual shall have the option of selecting a Medicaid-enrolled provider that can appropriately meet the individual's needs.

F. A participating provider may voluntarily terminate its participation in Medicaid by providing 30 days' written notification to DMAS.

G. Except as otherwise provided by state or federal law, DMAS may terminate at will a provider's participation agreement on 30 days' written notice as specified in the DMAS participation agreement. DMAS may immediately terminate a provider's participation agreement if the provider is no longer eligible to participate in the Medicaid program. Such action precludes further payment by DMAS for services provided to individuals on or after the date specified in the termination notice.

H. The provider or the managed care organization shall be responsible for completing the DMAS-225 form to notify the designated service authorization contractor and the local department of social services when any of the following events occur:

1. Home and community-based waiver services are started;

2. A waiver individual dies;

3. A waiver individual is discharged from the provider's CCC Plus Waiver services;

4. Any other events (including hospitalization) that cause home and community-based waiver services to cease or be interrupted for more than 30 consecutive calendar days; or

5. Changes in the individual's status that may affect the individual's patient pay amount or financial Medicaid eligibility.

I. Changes or termination of services.

1. The provider may decrease the amount of authorized care if the revised POC is appropriate and based on the medical needs of the waiver individual. The participating provider shall collaborate with the waiver individual or the family, caregiver, or EOR, as appropriate, to develop the new POC and calculate the new hours of service delivery. The provider shall discuss the decrease in care with the waiver individual or family, caregiver, or EOR, document the conversation in the waiver individual's record, and notify the designated service authorization contractor. The service authorization contractor shall process the decrease request and the waiver individual shall be notified of the change by letter. This letter shall clearly state the waiver individual's right to appeal this change.

2. If a change in the waiver individual's condition necessitates an increase in care, the participating provider shall assess the need for the increase and collaborate with the waiver individual and family, caregiver, or EOR, and MCO care coordinator as appropriate, to develop a POC for services to meet the changed needs. The provider may implement the increase in personal care hours prior to approval from DMAS, or the designated service authorization contractor, if the amount of services does not exceed the total amount established by DMAS as the maximum for the level of care designated for that individual on the plan of care.

3. Any increase to a waiver individual's POC that exceeds the number of hours allowed for that individual's level of care or any change in the waiver individual's level of care shall be authorized by DMAS or the designated service authorization contractor prior to the increase and be accompanied by adequate documentation justifying the increase.

4. In an emergency situation when the health, safety, or welfare of the waiver individual or provider personnel is endangered, the provider shall notify DMAS, or the designated service authorization contractor in writing prior to discontinuing services. The provider shall give written notification to the waiver individual discontinuing services. An advance written notification period shall not be required. If appropriate, local department of social services adult or child protective services shall be notified immediately.

5. In a nonemergency situation, when neither the health, safety, nor welfare of the waiver individual or provider personnel is endangered, the participating provider shall give the waiver individual at least 10 calendar days' written notification (plus three days for mail transit for a total of 13 calendar days from the letter's date) of the intent to discontinue services. The notification letter shall provide the reasons for and the effective date the provider will be discontinuing services.

J. Staff education and training requirements.

1. RNs shall (i) be currently licensed to practice in the Commonwealth as an RN, or shall hold multi-state licensure privilege pursuant to Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia; (ii) have at least one year of related clinical nursing experience, which may include work in an acute care hospital, public health clinic, home health agency, rehabilitation hospital, or nursing facility, specialized care nursing facility, or long-stay hospital or as an LPN who worked for at least one year in one of these settings; and (iii) meet the requirements of subdivision A 19 of this section regarding criminal record checks and consent to a search of the VDSS Child Protective Services Central Registry if the waiver individual is a minor child. The RN shall not be compensated for services provided to the waiver individual if this record check verifies that the RN has been convicted of a barrier crime described in § 32.1-162.9:1 of the Code of Virginia or if the RN has a founded complaint confirmed by the VDSS Child Protective Services Central Registry.

2. LPNs shall work under supervision as set out in 18VAC90-19-70. LPNs shall (i) be currently licensed to practice in the Commonwealth as an LPN, or shall hold multi-state licensure privilege pursuant to Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia; (ii) have at least one year of related clinical nursing experience, which may include work in an acute care hospital, public health clinic, home health agency, rehabilitation hospital, NF, specialized care NF, or long-stay hospital. The LPN shall meet the qualifications and skills, prior to being assigned to care for the waiver individual, that are required by the individual's POC; and (iii) meet the requirements of subdivision A 19 of this section regarding criminal record checks and consent to a search of the VDSS Child Protective Services Central Registry if the waiver individual is a minor child. The LPN shall not be compensated for services provided to the waiver individual if this record check verifies that the LPN has been convicted of a barrier crime described in § 32.1-162.9:1 of the Code of Virginia or if the LPN has a founded complaint confirmed by the VDSS Child Protective Services Central Registry.

3. All RNs and LPNs who provide PDN services shall have either (i) at least six months of related clinical experience as documented in their work history, which may include work in acute care hospitals, long-stay hospitals, rehabilitation hospitals, or specialized care nursing facilities, or (ii) completed a provider training program related to the care and technology needs of the assigned waiver individual.

a. Training programs established by providers shall include, at a minimum, the following:

(1) Trainers (either RNs or respiratory therapists) shall have at least six months hands-on successful experience in the areas in which the trainer provides training, such as ventilators, tracheostomies, peg tubes, and nasogastric tubes.

(2) Training shall include classroom time as well as direct hands-on demonstration of mastery by the trainee of the specialized skills required to work with individuals who have technology dependencies.

(3) The training program shall include the following subject areas as they relate to the care to be provided by the nurse: (i) human anatomy and physiology, (ii) medications frequently used by technology dependent individuals, (iii) emergency management, and (iv) the operation of the relevant equipment.

(4) Providers shall ensure a nurse's competency and mastery of the skills necessary to care successfully for a waiver individual prior to assignment. Documentation of successful completion of such training course and mastery of the specialized skills required to work with individuals who have technology dependencies shall be maintained in the provider's personnel records. This documentation shall be provided to DMAS upon request.

b. The RN supervisor for nurses providing PDN shall be currently licensed to practice nursing in the Commonwealth and have at least one year of related clinical nursing experience, which may include work in an acute care hospital, long-stay hospital, rehabilitation hospital, or specialized care nursing facility.

4. Personal care aides who are employed by personal care agencies that are licensed by VDH shall meet the requirements of 12VAC5-381. In addition, personal care aides shall also receive annually a minimum of 12 documented hours of agency-provided training in the performance of these services.

5. Personal care aides who are employed by personal care agencies that are not licensed by VDH shall have completed an educational curriculum of at least 40 hours of study related to the needs of individuals who are either elderly or who have disabilities, as ensured by the provider prior to being assigned to the care of an individual, and shall have the required skills and training to perform the services as specified in the waiver individual's POC and related supporting documentation.

a. Personal care aides' required initial (that is, at the onset of employment) training shall be met in one of the following ways: (i) registration with the Board of Nursing as a certified nurse aide; (ii) graduation from an approved educational curriculum as listed by the Board of Nursing; or (iii) completion of the provider's educational curriculum, which must be a minimum of 40 hours in duration, as taught by an RN who meets the same requirements as the RN listed in subdivision 1 of this subsection.

b. In addition, personal care aides shall also be required to receive annually a minimum of 12 documented hours of agency-provided training in the performance of these services, which shall be documented in the aide's record.

6. Personal care aides 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 personal care aide by the Social Security Administration;

e. Meet the requirements of subdivision A 19 of this section 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 CCC Plus Waiver requirements; and

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

7. Consumer-directed personal care attendants shall:

a. Be 18 years of age or older;

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

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

d. Have a valid social security number that has been issued to the personal care attendant by the Social Security Administration;

e. Meet the requirements of subdivision A 19 of this section 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 CCC Plus Waiver requirements;

g. Receive tuberculosis (TB) screening as specified in the criteria used by VDH; and

h. Be willing to attend training at the request of the individual, family, caregiver, or EOR.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; amended, Virginia Register Volume 31, Issue 10, eff. February 12, 2015; Volume 40, Issue 20, eff. June 19, 2024; Errata, 40:22 VA.R. 1892 June 17, 2024.

12VAC30-120-935. Participation standards for specific covered services.

A. The personal care providers, respite care providers, ADHC providers, private duty nursing providers, and services facilitators shall develop an individualized POC that addresses the waiver individual's service needs. Such plan shall be developed in collaboration with the waiver individual or the individual's family, caregiver, or EOR, as appropriate.

B. DMAS shall not reimburse for any waiver services rendered to waiver individuals when either (i) the spouse of the waiver individual or (ii) the natural, adoptive, step, or foster parent or other legal guardian of the minor child waiver individual is the one providing the service.

1. Payment shall not be made for personal care or respite services furnished by other family members living under the same roof as the waiver individual unless there is objective written documentation as to why no other person or provider is available to render the service. The nurse supervisor or services facilitator shall initially make the determination and document it fully in the individual's record.

2. Payment shall not be made for AT, EM, transition services, or services facilitation services furnished by other family members living under the same roof as the waiver individual receiving services.

3. Payment shall not be made for PDN services furnished by other family members, legal guardians of the waiver individual, or other persons living under the same roof as the waiver individual receiving the service.

4. Family members who are approved to be reimbursed for providing personal care or respite care services shall meet the same qualifications as all other personal care aides or CD attendants.

5. Payment shall not be made for respite care services if the primary caregiver, as identified in the records, receives payment for providing personal care services to the individual. Providers shall document the primary caregiver and whether the caregiver is paid or unpaid in the individual's record prior to requesting respite care service authorization.

C. Agency providers shall employ appropriately licensed professional staff who can provide the covered waiver services required by the waiver individual. Providers shall require that the supervising RN or LPN be available by phone at all times that the LPN or aide is providing services to the waiver individual.

D. Agency staff (RNs, LPNs, or aides) or CD attendants shall only be reimbursed by DMAS for services if they are physically present with the waiver individual and are awake to perform the services outlined in the individual's plan of care.

E. A single agency-directed aide, consumer-directed attendant, RN, or LPN who provides personal care or respite services shall be reimbursed at a maximum limit of 16 hours per day for services rendered to an individual in order to ensure the health and safety of the individual receiving these services.

F. Failure to provide the required services, conduct the required reviews, and meet the documentation standards as stated in this section shall result in audited providers returning overpayments to DMAS.

G. In addition to meeting the general conditions and requirements, home and community-based services participating providers shall also meet the following requirements:

1. ADHC services provider. In order to provide home and community-based services, adult day health center (ADHC) shall:

a. Hold a license with VDSS for adult day care center (ADCC) and make available a copy of the current VDSS license for DMAS review and verification prior to the provider applicant's enrollment as a Medicaid provider;

b. Meet and maintain compliance with provisions of home and community-based rules as detailed in the provider agreement and as described in 42 CFR 441.301; and

c. Employ the following:

(1) A director who shall be responsible for overall management of the center's programs and employees pursuant to 22VAC40-61-130. The director shall be the provider's contact person for DMAS and the designated service authorization contractor and shall be responsible for responding to communication from DMAS and the designated service authorization contractor. The director shall be responsible for ensuring the development of the POCs for waiver individuals. The director shall assign a staff member to act as the ADHC coordinator for each waiver individual and shall document the identity of the ADHC coordinator in each individual's record. The ADHC coordinator can be the director, the activities director, RN, or therapist. The ADHC coordinator shall be responsible for management of the waiver individual's POC and for its review with the program aides and any other staff, as necessary.

(2) An RN who shall be responsible for administering to and monitoring the health needs of waiver individuals. The RN may also contract with the center. The RN shall be responsible for the planning and implementation of the POC involving multiple services where specialized health care knowledge may be needed. The RN shall be present a minimum of eight hours each month at the center. DMAS may require the RN's presence at the center for more than this minimum standard depending on the number of waiver individuals who are in attendance and according to the medical and nursing needs of the waiver individuals who attend the center. Although DMAS does not require that the RN be a full-time staff position, there shall be an RN available, either in person or by telephone, to the center's waiver individuals and staff during all times that the center is in operation. The RN shall be responsible for:

(a) Providing periodic evaluation of the nursing needs of each waiver individual at least every 90 days or sooner when there is a change in the individual's ADHC level of care needs;

(b) Providing the nursing care and treatment as documented in the waiver individual's POC; and

(c) Monitoring, recording, and administering of prescribed medications or supervising the waiver individual in self-administered medication.

(3) Personal care aides who shall be responsible for overall care of waiver individuals such as assistance with ADLs, social or recreational activities, and other health and therapeutic-related activities. Each program aide hired by the provider shall be screened to ensure compliance with training and skill mastery qualifications required by DMAS. The aide shall, at a minimum, have the following qualifications:

(a) Be 18 years of age or older;

(b) Be able to read and write in English to the degree necessary to perform the tasks expected and create and maintain the required waiver individual documentation of services rendered;

(c) Be physically able to perform the work and have the skills required to perform the tasks required in the waiver individual's POC;

(d) Have a valid social security number issued to the program aide by the Social Security Administration;

(e) Have satisfactorily completed an educational curriculum as set out in this subdivision. Documentation of successful completion shall be maintained in the aide's personnel file and be available for review by DMAS staff. Prior to assigning a program aide to a waiver individual, the center shall ensure that the aide has either (i) registered with the Board of Nursing as a certified nurse aide; (ii) graduated from an approved educational curriculum as listed by the Board of Nursing; or (iii) completed the provider's educational curriculum, at least 40 hours in duration, as taught by an RN who is licensed in the Commonwealth or who holds a multi-state licensing privilege.

(4) An activities director who shall be responsible for directing recreational and social activities for the ADHC recipients. The director, at a minimum, shall have the following qualifications:

(a) A minimum of 48 semester hours or 72 quarter hours of post-secondary education from an accredited college or university with a degree in recreational therapy, occupational therapy, or a related field such as art, music, or physical education, and

(b) Have one year of related experience, which may include work in an acute care hospital, rehabilitation hospital, or nursing home, or have completed a course of study including the prescribed internship in occupation, physical, or recreational therapy or music, dance, art therapy, or physical education.

(5) The ADHC coordinator who shall coordinate, pursuant to 22VAC40-61-280, the delivery of the activities and services as prescribed in the waiver individual's POC and keep such plans updated, record 30-day progress notes concerning each waiver individual, and review the waiver individual's daily records each week. If a waiver individual's condition changes more frequently, more frequent reviews and recording of progress notes shall be required to reflect the individual's changing condition. Copied or re-dated notes are not acceptable.

d. Recreation and social activities responsibilities. The center shall provide planned recreational and social activities suited to the waiver individual's needs and interests and designed to encourage physical exercise, prevent deterioration of each waiver individual's condition, and stimulate social interaction.

e. The ADHC shall allow the care coordinator, DMAS, or the managed care organization to meet with waiver individuals to complete the annual individual experience survey, as required in the provisions of 42 CFR 441.301.

f. The center shall maintain all records of each Medicaid individual. These records shall be reviewed periodically by DMAS staff or its designated agent who is authorized by DMAS to review these files. At a minimum, these records shall contain:

(1) DMAS required forms as specified in the center's provider-appropriate guidance documents;

(2) Interdisciplinary POCs developed, in collaboration with the waiver individual, family, or caregiver, or both as may be appropriate, by the center's director, RN, and therapist, as may be appropriate, and any other relevant support persons;

(3) Documentation of interdisciplinary staff meetings that shall be held at least every three months to reassess each waiver individual, evaluate the adequacy of the POC, and make any necessary revisions;

(4) At a minimum, 30-day goal-oriented progress notes recorded by the designated ADHC coordinator. If a waiver individual's condition and treatment POC changes more often, progress notes shall be written more frequently than every 30 days (copied or re-dated notes are not acceptable);

(5) The daily record of services provided shall contain the specific services delivered by center staff. The record shall also contain the arrival and departure times of the waiver individual and shall be signed weekly by either the director, activities director, RN, or therapist employed by the center. The record shall be completed on a daily basis, neither before nor after the date of services delivery. At least once a week, a staff member shall chart significant comments regarding care given to the waiver individual. If the staff member writing comments is different from the staff signing the weekly record, that staff member shall sign the weekly comments. A copy of this record shall be given weekly to the waiver individual, family, or caregiver, and it shall also be maintained in the waiver individual's medical record; and

(6) All contacts shall be documented in the waiver individual's medical record, including correspondence made to and from the individual with family, caregivers, physicians, DMAS, the designated service authorization contractor, formal and informal services providers, and all other professionals related to the waiver individual's Medicaid services or medical care.

2. Agency-directed personal care services. The personal care provider agency shall hire or contract with and directly supervise an RN who provides ongoing supervision of all personal care aides and LPNs. LPNs may supervise, pursuant to their licenses, personal care aides based upon RN assessment of the waiver individual's health, safety, and welfare needs.

a. The RN supervisor shall make an initial home assessment visit on or before the start of care for all individuals admitted to personal care, when a waiver individual is readmitted after being discharged from services, or if the individual is transferred from another provider, ADHC, or other waiver service.

b. Within 30 days after the initial home assessment visit, the RN supervisor shall visit the individual and the individual's family or caregiver, as appropriate, to monitor the plan of care, to reassess the individual's needs, and to determine if the services rendered are adequate to ensure the health, safety, and welfare of the individual.

c. During a home visit, the RN supervisor shall evaluate, at least every 90 days, the LPN supervisor's performance and the waiver individual's needs to ensure the LPN supervisor's abilities to function competently and shall provide training as necessary. This shall be documented in the waiver individual's record. A reassessment of the individual's needs and review of the POC shall be performed and documented during these visits.

d. The nurse supervisor shall also make supervisory visits based on the assessment and evaluation of the care needs of waiver individuals as often as needed and as defined in this subdivision to ensure both quality and appropriateness of services.

(1) The personal care provider agency shall have the responsibility of determining when supervisory visits are appropriate for the waiver individual's health, safety, and welfare. Supervisory visits shall be at least every 90 days. This determination must be documented in the waiver individual's record by the RN on the initial assessment and in the ongoing assessment records.

(2) If DMAS determines that the waiver individual's health, safety, or welfare is in jeopardy, DMAS may require the provider's nurse supervisor to supervise the personal care aides more frequently than once every 90 days. These visits shall be conducted at this designated increased frequency until DMAS determines that the waiver individual's health, safety, or welfare is no longer in jeopardy. This shall be documented by the provider and entered into the individual's record.

(3) During visits to the waiver individual's home, the nurse supervisor shall observe, evaluate, and document the adequacy and appropriateness of personal care services with regard to the individual's current functioning status, medical needs, and social needs. The nurse supervisor shall review the record of the aide or LPN and discuss with the individual, family, or caregiver the satisfaction with the type and amount of services.

(4) If the nurse supervisor must be delayed in conducting the regular supervisory visit, such delay shall be documented in the waiver individual's record with the reasons for the delay. Such supervisory visits shall be conducted within 15 calendar days of the waiver individual's first availability.

(5) A nurse supervisor shall be available to the personal care aide for conferences pertaining to waiver individuals being served by the aide.

(a) The nurse supervisor shall be available to the aide by telephone at all times that the aide is providing services to waiver individuals.

(b) The nurse supervisor shall evaluate the personal care aide's performance and the waiver individual's needs to identify any insufficiencies in the personal care aide's abilities to function competently and shall provide training as indicated. This shall be documented in the waiver individual's record.

(6) Licensed practical nurses (LPNs). As permitted by the license, the LPN may supervise personal care aides. To ensure both quality and appropriateness of services, the LPN supervisor shall make supervisory visits of the aides as often as needed, but no fewer visits than provided in a waiver individual's POC as developed by the RN in collaboration with the individual and the individual's family or caregivers, or both, as appropriate.

(a) During visits to the waiver individual's home, an LPN-supervisor shall observe, evaluate, and document the adequacy and appropriateness of personal care services, the individual's current functioning status, medical needs and social needs. The personal care aide's record shall be reviewed and the waiver individual's, family's, or caregiver's, satisfaction with the type and amount of services discussed.

(b) The LPN supervisor shall evaluate the personal care aide's performance and the waiver individual's needs to identify any insufficiencies in the aide's abilities to function competently and shall provide training as required to resolve the insufficiencies. This shall be documented in the waiver individual's record and reported to the RN supervisor.

(c) An LPN supervisor shall be available to personal care aides for conferences pertaining to waiver individuals being served by them.

(7) Personal care aides. The agency provider may employ and the nurse supervisor shall directly supervise personal care aides who provide direct care to waiver individuals. Each aide hired to provide personal care shall be evaluated by the provider to ensure compliance with qualifications and skills required by DMAS pursuant to 12VAC30-120-930.

e. Required documentation for a waiver individual's records. The provider shall maintain all records for each individual receiving personal care services. These records shall be separate from those of non-home and community-based waiver services, such as companion or home health services. These records shall be reviewed periodically by DMAS or its designated agent. At a minimum, the record shall contain:

(1) All personal care aides' records (DMAS-90) to include (i) the specific services delivered to the waiver individual by the aide; (ii) the personal care aide's actual daily arrival and departure times; (iii) the aide's weekly comments or observations about the waiver individual, including observations of the individual's physical and emotional condition, daily activities, and responses to services rendered; and (iv) any other information appropriate and relevant to the waiver individual's care and need for services.

(2) The personal care aide's and individual's or responsible caregiver's signatures, including the date, shall be recorded on these records verifying that personal care services have been rendered during the week of the service delivery.

(a) An employee of the provider shall not sign for the waiver individual unless that employee is a family member or unpaid caregiver of the waiver individual.

(b) Signatures, times, and dates shall not be placed on the personal care aide record earlier than the last day of the week in which services were provided no more than seven calendar days from the date of the last service.

3. Agency-directed respite care services.

a. To be approved as a respite care provider with DMAS, the respite care agency provider shall:

(1) Employ or contract with and directly supervise either an RN or LPN, or both, who will provide ongoing supervision of all respite care aides or LPNs, as appropriate. An RN shall provide supervision to all direct care and supervisory LPNs.

(a) When respite care services are received on a routine basis, the minimum acceptable frequency of the required nurse supervisor's visits shall not exceed every 90 days, based on the initial assessment. If a waiver individual is also receiving personal care or private duty nursing services, the respite care nurse supervisory visit may coincide with the personal care nurse supervisory visits. However, the nurse supervisor shall document supervision of respite care separately from the personal care documentation. For this purpose, the same individual record may be used with a separate section for respite care documentation.

(b) When respite care services are not received on a routine basis but are episodic in nature, a nurse supervisor shall conduct the home supervisory visit with the aide or LPN on or before the start of care. The RN or LPN shall review the utilization of respite services either every six months or upon the use of half of the approved respite hours, whichever comes first. If a waiver individual is also receiving personal care services from the same provider, the respite care nurse supervisory visit may coincide with the personal care nurse supervisory visit.

(c) During visits to the waiver individual's home, the nurse supervisor shall observe, evaluate, and document the adequacy and appropriateness of respite care services to the waiver individual's current functioning status, medical needs, and social needs. The nurse supervisor shall review the record of the aide or LPN and discuss with the individual, family, or caregiver the satisfaction with the type and amount of services.

(d) Should the required nurse supervisory visit be delayed, the reason for the delay shall be documented in the waiver individual's record. This visit shall be completed within 15 days of the waiver individual's first availability.

(2) Employ or contract with aides to provide respite care services who shall meet the same education and training requirements as personal care aides.

(3) Employ an LPN or RN to perform skilled respite care services when skilled respite services are offered. Such services shall be reimbursed by DMAS under the following circumstances:

(a) The waiver individual shall have a documented need for routine skilled respite care that cannot be provided by unlicensed personnel, such as an aide. These waiver individuals would typically require a skilled level of care involving, for example but not necessarily limited to, ventilators for assistance with breathing or either nasogastric or gastrostomy feedings;

(b) No other person in the waiver individual's support system is willing and able to supply the skilled component of the individual's care during the unpaid primary caregiver's absence; and

(c) The waiver individual is unable to receive skilled nursing visits from any other source that could provide the skilled care usually given by the unpaid primary caregiver.

(4) Document in the waiver individual's record the circumstances that require the provision of skilled respite services by an LPN or RN. At the time of the LPN's or RN's service, the LPN or RN shall also provide all of the skilled respite services normally provided by an aide.

b. Required documentation for a waiver individual's records. The provider shall maintain all records for each waiver individual receiving respite services. These records shall be clearly labeled and maintained separately from those of non-home and community-based waiver services, such as companion or home health services. These records shall be reviewed periodically either by the DMAS staff or a contracted entity who is authorized by DMAS to review these records. At a minimum these records shall contain:

(1) Forms as specified in the DMAS guidance documents.

(2) All respite care LPN, RN, or aide records shall contain:

(a) The specific services delivered to the waiver individual by the LPN, RN, or aide;

(b) The respite care LPN's, RN's, or aide's daily arrival and departure times;

(c) Comments or observations recorded weekly about the waiver individual. LPN, RN, or aide comments shall include observation of the waiver individual's physical, medical, and emotional condition, daily activities, the individual's response to services rendered, and documentation of vital signs if taken as part of the POC.

(3) Skilled respite care LPN or RN records, which may be documented on the DMAS 90-A, shall be reviewed and signed by the supervising RN and shall contain:

(a) The signatures of the skilled respite care LPN or RN and waiver individual or responsible family or caregiver, including the date, verifying that skilled respite care services have been rendered during the week of service delivery as documented in the record.

(b) An employee of the provider shall not sign for the waiver individual unless the employee is a family member or unpaid caregiver of the waiver individual.

(c) Signatures, times, and dates shall not be placed on the skilled respite care LPN or aide record earlier than the last day of the week in which services were provided. Nor shall signatures be placed on the respite care LPN or aide records later than seven calendar days from the date of the last service.

4. Consumer-directed (CD) services facilitation for personal care and respite services.

a. Any services rendered by attendants prior to dates authorized by DMAS or the service authorization contractor shall not be eligible for Medicaid reimbursement and shall be the responsibility of the waiver individual.

b. If the services facilitator is not an RN, then the services facilitator shall inform the primary health care provider for the individual that services are being provided within 30 days from the start of such services and request consultation with the primary health care provider, as needed. This shall be done after the services facilitator secures written permission from the individual to contact the primary health care provider. The documentation of this written permission to contact the primary health care provider shall be retained in the individual's medical record. All contacts with the primary health care provider shall be documented in the individual's medical record.

c. The services facilitator or any staff or volunteer of the services facilitator providing direct service to Medicaid individuals shall meet the following qualifications:

(1) To be enrolled as a Medicaid services facilitator and maintain provider status, the services facilitator shall have sufficient knowledge, skills, and abilities to perform the activities required of such providers. In addition, the services facilitator shall have the ability to maintain and retain business and professional records sufficient to fully and accurately document the nature, scope, and details of the services provided.

(2) Effective January 11, 2016, all services facilitators and volunteers providing direct service to Medicaid individuals shall:

(a) Have a satisfactory work record as evidenced by at least two references from prior job experience with no evidence of abuse, neglect, or exploitation of incapacitated or older adults or children. In instances of employees who have worked for only one employer, such employees shall be permitted to provide one appropriate employment reference and one appropriate personal reference, including no evidence of abuse, neglect, or exploitation of incapacitated or older adults or children.

(b) Within 30 calendar days of employment, the services facilitator, staff, or volunteer shall obtain an original criminal record clearance with respect to convictions for offenses specified in § 19.2-392.02 of the Code of Virginia or an original criminal history record from the Central Criminal Records Exchange. The staff or volunteer shall also submit to a screening through the VDSS Child Protective Services (CPS) Central Registry if serving a waiver individual who is a minor child. Provider staff and volunteers shall not be reimbursed for services provided to the waiver individual effective on the date and thereafter that the VDSS CPS Central Registry check confirms the provider's staff person or volunteer has a finding.

(i) DMAS shall not reimburse a provider for services provided by a staff or volunteer who works in a position that involves direct contact with a waiver individual until an original criminal record clearance or original criminal history record has been received. DMAS shall reimburse services provided by such a staff person during only the first 30 calendar days of employment if the provider can produce documented evidence that such person worked only under the direct supervision of another staff person for whom a background check was completed in accordance with the requirements of this section. If an original criminal record clearance or original criminal history record is not received within the first 30 calendar days of employment, DMAS shall not reimburse the provider for services provided by such staff or volunteer on the 31st calendar day through the date on which the provider receives an original criminal record clearance or an original criminal history record.

(ii) DMAS shall not reimburse a provider for services provided by a staff or volunteer who has been convicted of any offense set forth in clause (i) of the definition of barrier crime in § 19.2-392.02 of the Code of Virginia unless all of the following conditions are met: (i) the offense was punishable as a misdemeanor; (ii) the staff or volunteer has been convicted of only one such offense; (iii) the offense did not involve abuse or neglect; and (iv) at least five years have elapsed since the conviction.

(c) The staff or volunteer shall provide the hiring entity with a sworn statement or affirmation disclosing any criminal convictions or any pending criminal charges, whether within or outside of the Commonwealth.

(d) Not be debarred, suspended, or otherwise excluded from participating in federal health care programs, as listed on the federal List of Excluded Individuals/Entities (LEIE) database at https://www.oig.hhs.gov.

(3) Effective January 11, 2016, all services facilitators shall possess the required degree and experience, as follows:

(a) Prior to initial enrollment by DMAS as a services facilitator or being hired by a Medicaid-enrolled services facilitator provider, all new applicants shall possess, at a minimum, either (i) an associate's degree from an accredited college in a health or human services field or be a registered nurse currently licensed to practice in the Commonwealth and possess a minimum of two years of satisfactory direct care experience supporting individuals with disabilities or older adults; or (ii) a bachelor's degree in a non-health or human services field and possess a minimum of three years of satisfactory direct care experience supporting individuals with disabilities or older adults.

(b) Persons who are services facilitators prior to January 11, 2016, shall not be required to meet the degree and experience requirements of subdivision 4 c (3) (a) of this subsection unless required to submit a new application to be a services facilitator after January 11, 2016.

(4) Effective April 10, 2016, all services facilitators shall complete required training and competency assessments. Satisfactory competency assessment results shall be kept in the service facilitator's record. All new services facilitators shall complete training and pass the corresponding competency assessment with a score of at least 80% in order to begin and to continue being reimbursed for or working with waiver individuals for the purpose of reimbursement for services through this waiver.

(5) As a component of the renewal of the Medicaid provider agreement, all services facilitators shall pass the competency assessment every five years and achieve a score of at least 80%.

(6) The services facilitator shall have access to a computer with Internet access that meets the security standards of Subpart C of 45 CFR Part 164 for the electronic exchange of information. Electronic exchange of information shall include, for example, checking individual eligibility, submission of service authorizations, submission of information to the fiscal employer agent, and billing for services.

(7) The services facilitator must possess a combination of work experience and relevant education that indicates possession of the following knowledge, skills, and abilities. Such knowledge, skills, and abilities must be documented on the services facilitator's application form, found in supporting documentation, or be observed during a job interview. Observations during the interview must be documented. The knowledge, skills, and abilities include:

(a) Knowledge of:

(i) Types of functional limitations and health problems that may occur in individuals with disabilities or older adults, as well as strategies to reduce limitations and health problems;

(ii) Physical care that may be required by individuals with disabilities or older adults, such as transferring, bathing techniques, bowel and bladder care, and the approximate time those activities normally take;

(iii) Equipment and environmental modifications that may be required by individuals with disabilities or older adults that reduce the need for human help and improve safety;

(iv) Various long-term care program requirements, including institutional and assisted living facility placement criteria, Medicaid waiver services, and other federal, state, and local resources that provide personal care and respite services;

(v) CCC Plus Waiver requirements, as well as the administrative duties for which the services facilitator will be responsible;

(vi) How to conduct assessments (including environmental, psychosocial, health, and functional factors) and their uses in services planning;

(vii) Interviewing techniques;

(viii) The individual's right to make decisions about, direct the provisions of, and control one's own consumer-directed services, including hiring, training, managing, approving the work shift entries of, and firing of an attendant;

(ix) The principles of human behavior and interpersonal relationships; and

(x) General principles of record documentation.

(b) Skills in:

(i) Negotiating with individuals, family, caregivers, and service providers;

(ii) Assessing, supporting, observing, recording, and reporting behaviors;

(iii) Identifying, developing, or providing services to individuals with disabilities or older adults; and

(iv) Identifying services within the established services system to meet the individual's needs.

(c) Abilities to:

(i) Report findings of the assessment or onsite visit, either in writing or an alternative format for individuals who have visual or hearing impairments;

(ii) Demonstrate a positive regard for individuals and their families;

(iii) Be persistent and remain objective;

(iv) Work independently, performing job position duties under general supervision;

(v) Communicate effectively orally and in writing; and

(vi) Develop a rapport and communicate with individuals from diverse cultural backgrounds.

(8). Failure to satisfy the competency assessment requirements and meet all other requirements shall result in a retraction of Medicaid payment or the termination of the provider agreement, or both.

d. Initiation of services and service monitoring.

(1) Upon entry into consumer-directed services, the services facilitator shall make an initial comprehensive home visit at the primary residence of the individual to collaborate with the individual or the individual's family or caregiver, as appropriate, to identify the individual's needs, assist in the development of the plan of care with the waiver individual and individual's family or caregiver, as appropriate, and provide EOR management training within seven days of the initial visit. The initial comprehensive home visit shall be conducted only once upon the individual's entry into consumer-directed services. The individual shall receive one comprehensive visit per lifetime. If the individual changes service facilitators, the new services facilitator shall complete a reassessment visit in lieu of a comprehensive visit. The EOR management training shall be limited to one visit per EOR.

(2) Within 30 days after the initial comprehensive visit, the services facilitator shall visit the individual and the individual's family or caregiver, as appropriate, to monitor the plan of care, to reassess the individual's needs, and to determine if the services rendered are adequate to ensure the health, safety, and welfare of the individual. During this visit, the services facilitator, individual, EOR, and family or caregiver, as appropriate, shall agree to the frequency of routine visits, which shall be conducted at least every 90 days but no more frequently than every 30 days. The agreement shall be documented in the service facilitator's records.

(3) During the routine visit, the services facilitator shall continue to monitor the plan of care on an as-needed basis and shall conduct face-to-face meetings with the individual and may include the EOR, family, or caregiver. Such visits shall be documented in the individual's medical record.

(4) When respite is the sole service provided, the services facilitator shall review the utilization of consumer-directed respite services, either every six months or upon the use of half of the approved respite services hours, whichever comes first, and shall conduct a face-to-face meeting with the individual and may include the family or caregiver, as appropriate. Such visits shall be documented in the individual's record.

(5) Every six months, the services facilitator shall conduct a face-to-face reassessment visit with the individual and EOR, family, or caregiver, as appropriate. During the visit, the services facilitator shall review the individual's current functional and support status, review all services the individual receives, including the existing plan of care, discuss the individual's and EOR's satisfaction with services, update the plan of care as necessary, and submit new service authorization requests for personal care hours and other waiver services if necessary. The services facilitator shall not conduct a routine visit and reassessment visit during the same visit but shall submit reimbursement for only a reassessment visit.

(6) During all visits with the individual, the services facilitator shall observe, evaluate, and consult with the individual or EOR and may include the family or caregiver to document the adequacy and appropriateness of consumer-directed services with regard to the individual's current functioning, cognitive status, and medical and social needs. The services facilitator's written summary of the visit shall include at a minimum:

(a) Discussion with the waiver individual, family, caregiver, or EOR, as appropriate, concerning whether the service is adequate to meet the waiver individual's needs;

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

(c) Any special tasks performed by the consumer-directed attendant and the consumer-directed attendant's qualifications to perform these tasks;

(d) The individual's, family's, caregiver's, or EOR's satisfaction with the service;

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

(f) The presence or absence of the attendant during the services facilitator's visit; and

(g) The appropriateness of the EOR to fulfill the responsibilities of the role.

(7) The services facilitator shall provide follow-up management training to the individual or EOR, as appropriate, under the following circumstances:

(a) The training shall be requested by the individual or EOR. Training shall not be provided at the request of the services facilitator, family, caregiver, or attendant;

(b) The training shall be limited to the role and responsibilities of the EOR. Training shall not include duties that are to be performed by the attendant;

(c) The training shall be provided in a face-to-face visit; and

(d) The services facilitator shall utilize the management training service to reimburse for tuberculosis screening, cardiopulmonary resuscitation training, and influenza immunization for the attendant at the request of the EOR. Requests for reimbursement shall be limited to the exact cost of the activity. Documentation of the cost and receipt of such activities shall be maintained in the individual's record.

e. DMAS, its designated contractor, or the fiscal/employer agent shall request a criminal record check and a check of the VDSS Child Protective Services Central Registry if the waiver individual is a minor child, in accordance with 12VAC30-120-930, pertaining to the consumer-directed attendant on behalf of the waiver individual and report findings of these records checks to the EOR.

f. The services facilitator shall review and verify copies of work shift entries to ensure that the hours approved in the plan of care are being provided and are not exceeded. If discrepancies are identified, the services facilitator shall discuss these with the individual or EOR to resolve discrepancies and shall notify the fiscal/employer agent. The services facilitator shall also review the individual's plan of care to ensure that the individual's needs are being met. Failure to conduct such reviews and verifications of work shift entries and maintain the documentation of these reviews shall result in a recovery by DMAS of payments made in accordance with 12VAC30-80-130.

g. The services facilitator shall maintain records of each individual served. At a minimum, these records shall contain:

(1) Results of the initial comprehensive home visit completed prior to or on the date services are initiated and subsequent reassessments and changes to the supporting documentation;

(2) The personal care plan of care. Such plans shall be reviewed by the provider every 90 days, annually, and more often as needed, and modified as appropriate. The respite services plan of care shall be included in the record and shall be reviewed by the provider every six months or when half of the approved respite service hours have been used whichever comes first. For the annual review and in cases where either the personal care or respite care plan of care is modified, the plan of care shall be reviewed with the individual, the family or caregiver, and EOR, as appropriate;

(3) The services facilitator's dated notes documenting any contacts with the individual, family, caregiver, or EOR and visits to the individual (copied or re-dated notes are not acceptable);

(4) All contacts, including correspondence, made to and from the individual, EOR, family or caregiver, physicians, DMAS, the designated service authorization contractor, MCO, formal and informal services provider, and all other professionals related to the individual's Medicaid services or medical care;

(5) All employer management training provided to the individual or EOR to include, for example, (i) receipt of training on the individual's or EOR's responsibilities for the accuracy of the consumer-directed attendant's work shift entries and (ii) the availability of the Consumer-Directed Employer of Record Manual available at http://dmas.virginia.gov;

(6) All documents signed by the individual or EOR, as appropriate, that acknowledge the responsibilities as the employer; and

(7) The DMAS required forms as specified in the DMAS Commonwealth Coordinated Care Plus Waiver Manual.

Failure to maintain all required documentation shall result in action by DMAS to recover payments made in accordance with 12VAC30-80-130. Repeated instances of failure to maintain documentation may result in cancellation of the Medicaid provider agreement.

h. In instances when the individual is consistently unable either to hire or retain the employment of a personal care attendant to provide consumer-directed personal care or respite services such as, for example, a pattern of discrepancies with the attendant's work shift entries, the services facilitator shall make arrangements, after conferring with DMAS or the managed care organization, to have the needed services transferred to an agency-directed services provider of the individual's choice or discuss with the individual, family, caregiver, or EOR other service options.

i. Waiver individual, family or caregiver, and EOR responsibilities.

(1) The individual shall be authorized for the consumer-directed model of service, and the EOR shall successfully complete EOR management training performed by the services facilitator before the individual or EOR shall be permitted to hire a consumer-directed attendant for Medicaid reimbursement. Any service that may be rendered by a consumer-directed attendant prior to authorization by Medicaid shall not be eligible for reimbursement by Medicaid. Individuals who are eligible for consumer-directed services shall have the capability to hire and train their own consumer-directed attendants and supervise the consumer-directed attendants' performances. In lieu of handling their consumer-directed attendants themselves, individuals may have a family or caregiver, or other designated person serve as the EOR on their behalf. The EOR shall be prohibited from also being the Medicaid-reimbursed consumer-directed attendant for respite or personal care or the services facilitator for the individual.

(2) Individuals shall acknowledge that consumer-directed personal care services shall not continue when the service is no longer appropriate or necessary for the individual's care needs and that the individual shall inform the services facilitator of a change in care needs. If the consumer-directed model of services continues after services have been terminated by DMAS or the designated service authorization contractor, the individual shall be held liable for the consumer-directed attendant compensation.

(3) Individuals shall notify the services facilitator of all hospitalizations or admissions, for example, any rehabilitation hospital, rehabilitation hospital unit, nursing facility, specialized care nursing facility, or long-stay hospital as consumer-directed attendant services shall not be reimbursed during such admissions. Failure to do so may result in the individual being held liable for the consumer-directed employee compensation.

5. Personal emergency response systems. In addition to meeting the general conditions and requirements for home and community-based waiver services participating providers as specified in 12VAC30-120-930, PERS providers must also meet the following qualifications and requirements:

a. A PERS provider shall be a personal care agency, a durable medical equipment provider, a licensed home health provider, or a PERS manufacturer. All such providers shall have the ability to provide PERS equipment, direct services (i.e., installation, equipment maintenance, and service calls), and PERS monitoring;

b. The PERS provider shall provide an emergency response center with fully trained operators who are capable of (i) receiving signals for help from an individual's PERS equipment 24 hours a day, 365 or 366 days per year, as appropriate; (ii) determining whether an emergency exists; and (iii) notifying an emergency response organization or an emergency responder that the PERS individual needs emergency help;

c. A PERS provider shall comply with all applicable Virginia statutes, all applicable regulations of DMAS, and all other governmental agencies having jurisdiction over the services to be performed;

d. The PERS provider shall have the primary responsibility to furnish, install, maintain, test, and service the PERS equipment, as required, to keep it fully operational. The provider shall replace or repair the PERS device within 24 hours of the waiver individual's notification of a malfunction of the console unit, activating devices, or medication monitoring unit and shall provide temporary equipment, as may be necessary for the waiver individual's health, safety, and welfare, while the original equipment is being repaired or replaced;

e. The PERS provider shall install, consistent with the manufacturer's instructions, all PERS equipment into a waiver individual's functioning telephone line or system within seven days of the request of such installation unless there is appropriate documentation of why this timeframe cannot be met. The PERS provider shall furnish all supplies necessary to ensure that the system is installed and working properly. The PERS provider shall test the PERS device monthly, or more frequently if needed, to ensure that the device is fully operational;

f. The PERS installation shall include local seize line circuitry, which guarantees that the unit shall have priority over the telephone connected to the console unit should the telephone be off the hook or in use when the unit is activated;

g. A PERS provider shall maintain a data record for each waiver individual at no additional cost to DMAS or the waiver individual. The record shall document all of the following:

(1) Delivery date and installation date of the PERS equipment;

(2) Waiver individual or caregiver signature verifying receipt of the PERS equipment;

(3) Verification by a monthly test that the PERS device is operational;

(4) The waiver individual's contact information, to be updated annually or more frequently as needed, as provided by the individual or the individual's caregiver or EOR;

(5) A case log documenting the waiver individual's utilization of the system, all contacts, and all communications with the individual, caregiver or EOR, and responders;

(6) Documentation that the waiver individual is able to use the PERS equipment through return demonstration; and

(7) Copies of all equipment checks performed on the PERS unit;

h. The PERS provider shall have backup monitoring capacity in case the primary system cannot handle incoming emergency signals;

i. The emergency response activator shall be capable of being activated either by breath, touch, or some other means and shall be usable by waiver individuals who are visually or hearing impaired or physically disabled. The emergency response communicator shall be capable of operating without external power during a power failure at the waiver individual's home for a minimum period of 24 hours. The emergency response console unit shall also be able to self-disconnect and redial the backup monitoring site without the waiver individual resetting the system in the event it cannot get its signal accepted at the response center;

j. PERS providers shall be capable of continuously monitoring and responding to emergencies under all conditions, including power failures and mechanical malfunctions. It shall be the PERS provider's responsibility to ensure that the monitoring agency and the monitoring agency's equipment meet the following requirements. The PERS provider shall be capable of simultaneously responding to multiple signals for help from the waiver individuals' PERS equipment. The PERS provider's equipment shall include the following:

(1) A primary receiver and a backup receiver, which shall be independent and interchangeable;

(2) A backup information retrieval system;

(3) A clock printer, which shall print out the time and date of the emergency signal, the waiver individual's identification code, and the emergency code that indicates whether the signal is active, passive, or a responder test;

(4) A backup power supply;

(5) A separate telephone service;

(6) A toll-free number to be used by the PERS equipment in order to contact the primary or backup response center; and

(7) A telephone line monitor, which shall give visual and audible signals when the incoming telephone line is disconnected for more than 10 seconds;

k. The PERS provider shall maintain detailed technical and operation manuals that describe PERS elements, including the installation, functioning, and testing of PERS equipment; emergency response protocols; and recordkeeping and reporting procedures;

l. The PERS provider shall document and furnish within 30 days of the action taken, a written report for each emergency signal that results in action being taken on behalf of the waiver individual. This excludes test signals or activations made in error. This written report shall be furnished to (i) the personal care provider; (ii) the respite care provider; (iii) the services facilitation provider; (iv) in cases where the individual only receives ADHC services, to the ADCC provider; or (v) to the transition coordinator for the service in which the individual is enrolled; and

m. The PERS provider shall obtain and keep on file a copy of the most recently completed DMAS-225 form. Until the PERS provider obtains a copy of the DMAS-225 form, the PERS provider shall clearly document efforts to obtain the completed DMAS-225 form from the personal care provider, respite care provider, services facilitation provider, or ADCC provider.

6. Assistive technology (AT) and environmental modification (EM) services. AT and EM shall be provided only to waiver individuals by providers who have current provider participation agreements with DMAS.

a. AT shall be rendered by providers having a current provider participation agreement with DMAS as durable medical equipment and supply providers. An independent, professional consultation shall be obtained, as may be required, from qualified professionals who are knowledgeable of that item for each AT request prior to approval by either DMAS or the service authorization contractor and may include training on such AT by the qualified professional. Independent, professional consultants shall include speech or language therapists, physical therapists, occupational therapists, physicians, behavioral therapists, certified rehabilitation specialists, or rehabilitation engineers. Providers that supply AT for a waiver individual may not perform assessment or consultation, write specifications, or inspect the AT for that individual. AT shall be delivered within 60 days from the start date of the authorization. The AT provider shall ensure that the AT functions properly.

b. In addition to meeting the general conditions and requirements for home and community-based waiver services participating providers as specified in 12VAC30-120-930, as appropriate, environmental modifications shall be provided in accordance with all applicable state or local building codes by contractors who have provider agreements with DMAS. Modifications shall be completed within a year of the start date of the authorization.

c. Providers of AT and EM services shall not be permitted to recover equipment that has been provided to waiver individuals whenever the provider has been charged, by either DMAS or its designated service authorization agent, with overpayments and is therefore being required to return payments to DMAS.

d. Providers of AT and EM services shall maintain in each individual's record all supporting documentation of the costs and estimates of the service. Should there be a change in the cost of the service, the new cost and estimate documentation shall also be included along with justification of the change in cost.

7. Transition services. This service shall be provided consistent with Part XX (12VAC30-120-2000 et seq.) of 12VAC30-120.

8. Private duty nursing (PDN).

a. This service shall be provided through a home health agency licensed or certified by VDH for Medicaid participation and with which DMAS has a contract for either PDN or congregate PDN or both.

b. The provider shall operate from a business office.

c. The provider shall employ (or subcontract with) and directly supervise an RN or an LPN. The LPN and RN shall be currently licensed to practice in the Commonwealth. Prior to providing PDN services, the RN or LPN shall have either (i) at least six months of related clinical nursing experience or (ii) completed a provider training program related to the care and technology needs of the waiver individual as described in 12VAC30-120-930 J 3. Regardless of whether a nurse has six months of experience or completes a provider training course, the provider agency shall be responsible for assuring all nurses who are assigned to an individual are competent in the care needs of that individual.

d. As part of direct supervision, the RN supervisor shall make, at a minimum, a visit every 30 days to ensure both quality and appropriateness of PDN to assess the individual's and the family's or caregiver's satisfaction with the services being provided, to review the medication and treatments, and to update and verify that the most current physician signed orders are in the home record.

(1) The waiver individual shall be present when the supervisory visits are made;

(2) At least every other visit shall be in the individual's primary residence;

(3) When a delay occurs in the RN supervisor's visits because the individual is unavailable, the reason for the delay shall be documented in the individual's record, and the visit shall occur as soon as the individual is available. Failure to meet this standard may result in a DMAS recovery of payments made; and

(4) Additional supervisory visits may be required under the following circumstances: (i) at the provider's discretion; (ii) at the request of the individual; (iii) when a change in the individual's condition has occurred; (iv) any time the health, safety, or welfare of the individual could be at risk; and (v) at the request of the DMAS staff.

e. When skilled respite services are routine in nature and offered in conjunction with personal care (PC) services for adults, the RN supervisory visit conducted for personal care may serve as the supervisory visit for respite services. However, the supervisor shall document supervision of skilled respite services separately. For this purpose, the same individual record can be used with a separate section clearly labeled for documentation of skilled respite services.

f. For DMAS-enrolled PDN providers that also provide PC services, the provider shall employ or subcontract with and directly supervise an RN who will provide ongoing supervision of all personal care aides. The supervising RN shall be currently licensed to practice nursing in the Commonwealth and have at least one year of related clinical nursing experience, which may include work in an acute care hospital, long-stay hospital, rehabilitation hospital, nursing facility, or specialized care nursing facility. In addition to meeting the general conditions and requirements for home and community-based waiver services participating providers as specified in 12VAC30-120-930 and this section for PDN, providers shall also comply with the requirements of this section in the provision of PC services.

g. The following documentation shall be maintained for every individual for whom DMAS-enrolled providers render these services:

(1) Physicians' orders for these services shall be maintained in the individual's record as well as at the individual's primary residence. All recertifications of the POC shall be performed within the last five business days of each current 60-day period. The physician shall sign the recertification before Medicaid reimbursement shall occur;

(2) All assessments, reassessments, and evaluations (including the complete LTSS screening packet or risk evaluations) made during the provision of services, including any required initial assessments by the RN supervisor completed prior to or on the date services are initiated and changes to the supporting documentation by the RN supervisor;

(3) Progress notes reflecting the individual's status and, as appropriate, progress toward the identified goals in the POC (copied or re-dated notes are not acceptable);

(4) All related communication with the individual and the individual's representative, the DMAS-designated agent for service authorization, consultants, DMAS, VDSS, formal and informal service providers, all required referrals, as appropriate, to adult protective services or child protective services and all other professionals concerning the individual;

(5) All service authorization decisions rendered by the DMAS staff or the DMAS-designated service authorization contractor;

(6) All POCs completed with the individual, family, or caregiver, as appropriate, and specific to the service being provided and all supporting documentation related to any changes in the POC; and

(7) Notes of any verbal or nonverbal cues, motions, signals, or actions the individual makes to indicate distress or uses to call in case of an emergency. The individual, primary caregiver, or family, as appropriate, shall share this information with the RN or LPN at the onset of services. Documentation of these cues shall be kept in the individual's record and shall be reviewed periodically to ensure the individual is still able to perform these cues.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 31, Issue 10, eff. February 12, 2015; amended, Virginia Register Volume 35, Issue 2, eff. October 27, 2018; Errata 35:3 VA.R. 502 October 1, 2018; amended, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-940. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; repealed, Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

12VAC30-120-945. Payment for covered services.

A. DMAS shall not reimburse providers, either agency-directed or consumer-directed, for any staff training required by these waiver regulations or any other training that may be required.

B. All services provided in the CCC Plus Waiver shall be reimbursed at a rate established by DMAS in its agency fee schedule.

1. DMAS or its contractor shall reimburse a per diem fee for ADHC services that shall be considered as payment in full for all services rendered to that waiver individual as part of the individual's approved ADHC plan of care.

2. Personal care (agency-directed and consumer-directed), respite (agency-directed and consumer-directed), and PDN care services shall be reimbursed on an hourly basis consistent with the agency's fee schedule. Effective July 1, 2021, a single consumer-directed attendant who provides personal care or respite services shall be reimbursed at the regular rate for up to 40 hours per week for authorized services rendered and at one and a half times the regular rate for up to 16 hours per week beyond 40 hours. This shall not apply to consumer-directed attendants who are exempt from overtime requirements under 29 USC § 552.102 of the federal Fair Labor Standards Act, 29 USC § 201 et seq.

3. Transition services. The total costs of these transition services shall be limited to $5,000 per waiver individual per lifetime and shall be expended within nine months from the start date of authorization. Transition services shall be reimbursed at the actual cost of the item; no mark ups shall be permitted.

4. Reimbursement for assistive technology (AT) and environmental modification (EM) services shall be as follows:

a. All AT services provided in the CCC Plus Waiver shall be reimbursed as a service limit of one and up to a per member annual maximum of $5,000 per calendar year regardless of waiver. These limits shall apply regardless of whether the waiver individual remains in this waiver or changes to another waiver program. AT services shall be reimbursed in a manner that is reasonable and customary not to exceed the provider's usual and customary charges to the general public. No markups shall be permitted.

b. All EM services provided in the CCC Plus Waiver shall be reimbursed as a service limit of one and up to a per member annual maximum of $5,000 per calendar year regardless of waiver. These limits shall apply regardless of whether the individual remains in this waiver or changes to another waiver program. All EM services shall be reimbursed at the actual cost of material and labor and no mark ups shall be permitted.

5. PERS monthly fee payments shall be consistent with the agency's fee schedule.

C. Duplication of services.

1. DMAS shall not duplicate services that are required as a reasonable accommodation as a part of the American with Disabilities Act (42 USC §§ 12131 through 12165), the Rehabilitation Act of 1973 (29 USC § 794), or the Virginians with Disabilities Act (§ 51.5-1 et seq. of the Code of Virginia).

2. Payment for waiver services shall not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. All private insurance benefits for these waiver-covered services shall be exhausted before Medicaid reimbursement can occur as Medicaid shall be the payer of last resort.

3. DMAS payments for EM services shall not be duplicative in homes where multiple waiver individuals reside.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 31, Issue 10, eff. February 12, 2015; amended, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-950. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; repealed, Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

12VAC30-120-960. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; repealed, Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

12VAC30-120-970. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; amended, Virginia Register Volume 25, Issue 20, eff. July 9, 2009; repealed, Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

12VAC30-120-980. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; repealed, Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

12VAC30-120-990. Quality management review; utilization review; level of care (LOC) reviews..

A. DMAS shall perform quality management reviews for the purpose of assuring high quality of service delivery consistent with the attending physicians' orders, approved POCs, service authorized services for the waiver individuals, and DMAS compliance with CMS assurances. Providers identified as not meeting the standards consistent with such orders, POCs, and service authorizations shall be required to submit corrective action plans (CAPs) to DMAS for approval. Once approved, such CAPs shall be implemented to resolve the cited deficiencies.

B. If DMAS staff determines, during any review or at any other time, that the waiver individual no longer meets the criteria for participation in the waiver (such as functional dependencies, medical/nursing needs, risk of NF placement, or Medicaid financial eligibility), then DMAS staff, as appropriate, shall deny payment for waiver services for such waiver individual and the waiver individual shall be discharged from the waiver.

C. Securing service authorization shall not necessarily guarantee reimbursement pursuant to DMAS utilization review of waiver services.

D. Failure to meet documentation requirements and supervisory reviews in a timely manner may result in either a plan of corrective action or retraction of payments.

E. Once waiver enrollment occurs, Level of Care Eligibility Re-determination audits (LOCERI) shall be performed at DMAS.

1. This independent electronic calculation of eligibility determination is performed and communicated to the DMAS supervisor. Any individual whose LOCERI audit shows failure to meet eligibility criteria shall receive a second manual review and may receive a home visit by DMAS staff.

2. The agency provider and the CD services facilitator shall submit to DMAS upon request an updated DMAS-99 LOC form, information from a current DMAS-97 A/B form, and, if applicable, the DMAS-225 form for designated waiver individuals. This information is required by DMAS to assess the waiver individual's ongoing need for Medicaid-funded long-term care and appropriateness and adequacy of services rendered.

F. DMAS or its designated agent shall periodically review and audit providers' records for these services for conformance to regulations and policies and concurrence with claims that have been submitted for payment. When a waiver individual is receiving multiple services, the records for all services shall be separated from those of non-home and community-based care services, such as companion or home health services. Failure to maintain the required documentation may result in DMAS' determination of overpayments against providers and requiring such providers to repay these overpayments pursuant to § 32.1-325.1 of the Code of Virginia.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

12VAC30-120-995. Appeals.

A. Providers shall have the right to appeal actions taken by DMAS. Provider appeals shall be considered pursuant to § 32.1-325.1 of the Code of Virginia and the Virginia Administrative Process Act (§ 2.2-4000 et seq.) of the Code of Virginia and DMAS regulations at 12VAC30-10-1000 and Part XI (12VAC30-20-500 et seq.) of 12VAC30-20.

B. Individuals shall have the right to appeal actions taken by DMAS. Individuals' appeals shall be considered pursuant to 12VAC30-110-10 through 12VAC30-110-370. DMAS shall provide the opportunity for a fair hearing, consistent with 42 CFR Part 431, Subpart E.

C. The individual shall be advised in writing of such denial and of his right to appeal consistent with DMAS client appeals regulations 12VAC30-110-70 and 12VAC30-110-80.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

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