12VAC30-130-460. Directions for applying the criteria.

Part VI. Criteria for Intermediate Care for Mentally Retarded Persons

12VAC30-130-430. Introduction.

A. Utilization control regulations require that the level of care criteria be formulated for guidance for appropriate levels of care. Traditionally, intermediate care for the mentally retarded has been institutionally based; however, this level of care need not be confined to a specific setting. The habilitative and health needs of the client are the determining issues.

B. The purpose of this chapter is to establish standard criteria to measure eligibility for Medicaid payment. Medicaid can pay for care only when the client is in the appropriate level of care and when "active treatment" is being provided. An individual's need for care must meet these criteria before any authorization for payment by Medicaid will be made for either institutional or waivered rehabilitative services for the mentally retarded.

C. Intermediate care for the mentally retarded requires planned programs for habilitative needs or health related services which exceed the level or room, board, combination of habilitative, rehabilitative, and health services directed toward increasing the functional capacity of the retarded person. Examples of services will include training in the activities of daily living, task-learning skills, socially acceptable behaviors, basic community living programming, or health care and health maintenance. The overall objective of programming shall be the attainment of the optimal physical, intellectual, social, or task learning level which the person can presently or potentially achieve.

D. The evaluation and reevaluation for intermediate care are based on the needs of the person, the reasonable expectations of the resident's capabilities, the appropriateness of programming, whether progress is demonstrated from the training and, in an institution, whether the services could reasonably be provided in a less restrictive environment.

E. The final determination of a person's need for intermediate level of care is a professional decision based on total needs. Mentally retarded persons as individuals present an infinite variety of needs, making it virtually impossible to establish an evaluation system that will eliminate the need for professional judgement within the confines of program criteria.

F. The following criteria are divided into broad categories of needs, or services provided. These must be evaluated in detail to determine the abilities/skills which the client has acquired. The evaluation will then identify training needs/skills which will be the basis for the development of a plan of care.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-04-8.2 § 1, eff. December 26, 1985.

12VAC30-130-440. Definitions.

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:

"No assistance" means no help is needed.

"Often" means occurs two to three times a month.

"Prompting/structuring" means prior to the functioning, some verbal direction or rearrangement of the environment is needed.

"Rarely" means occurs quarterly or less.

"Regularly" means occurs weekly or more.

"Some direct assistance" means helper must be present and provide some physical guidance/support (with or without verbal direction).

"Sometimes" means occurs once a month.

"Supervision" means helper must be present during function and provide only verbal direction, gestural prompts, or guidance.

"Total assistance" means helper must perform all or nearly all of the functions.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-04-8.2 § 2, eff. December 26, 1985.

12VAC30-130-450. Patient assessment criteria.

A. The evaluation process will demonstrate a need for programming an array of skills and abilities or health care services. These have been organized into seven major categories. The level of functioning in each category is graded from the most dependent to the least dependent. In some categories, the dependency status is rated by the degree of assistance required. In other categories, the dependency is established by the frequency of a behavior or ability to perform a given task.

The resident must meet the indicated dependency level in two or more of the categories 1 through 7.

1. Health status. To meet this category:

a. Two or more questions must be answered with a "4," or

b. Question 10 must be answered "yes".

2. Communication skills. To meet this category:

a. Three or more questions must be answered with a "3" or "4".

3. Task learning skills. To meet this category:

a. Three or more questions must be answered with a "3" or "4".

4. Personal care. To meet this category:

a. Question No. 1 must be answered with a "4" or "5", or

b. Question No. 2 must be answered with a "4" or "5", or

c. Questions No. 3 and 4 must be answered with a "4" or "5".

5. Mobility. To meet this category:

a. Any one question must be answered with a "4" or "5".

6. Behavior. To meet this category:

a. Any one question must be answered with a "3" or "4".

7. Community living. To meet this category:

a. Any two of the questions numbers 2, 5, or 7 must be answered with a "4" or "5", or

b. Three or more of questions 1 through 8 must be answered with a "4" or "5".

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-04-8.2 § 3, eff. December 26, 1985.

12VAC30-130-460. Directions for applying the criteria.

A. The references under the questions in the following categories indicate those items which are on the Behavior Development Survey (DMH 71 Revised 6/80). The absence of a reference indicates this question is not addressed on the BDS form. Some categories on the Behavior Development Survey are not incorporated since the information in that area of the evaluation will be reflected elsewhere in the criteria or the condition is not indicative of a functional deficit justifying a need for intermediate care.

PATIENT ASSESSMENT CRITERIA.
1. HEALTH STATUS -- To meet this category:
	a.	Two or more questions must be answered with a 4, or Question No. 10 must be answered yes.
						Rarely					Some- times				Often				Regu- larly
	b.	How often is nursing care or nursing supervision by a licensed nurse required for the following:				1					2				3				4
		1.	Medication administration and/or evaluation for effectiveness of a medication regime? ((70) Receiving Medications and History of Seizures pg.4)			1					2				3				4
		2.	Direct services: i.e., care for lesions, dressings, treatments, (other than shampoos, foot powder, etc.)?			1					2				3				4
		3.	Seizures control? ((68) History of seizures pg.4)			1					2				3				4
		4.	Teaching diagnosed disease control and care, including diabetes?			1					2				3				4
		5.	Management of care of diagnosed circulatory or respiratory problems?			1					2				3				4
		6.	Motor disabilities which interfere with all activities of daily living--bathing, dressing, mobility, toileting, etc.?			1					2				3				4
		7.	Observation for choking/aspiration while eating, drinking?			1					2				3				4
		8.	Supervision for use of adaptive equipment, i.e., special spoon, braces, etc.? (physical aids pg.4)			1					2				3				4
		9.	Observation for nutritional problems (i.e., undernourishment, swallowing difficulties, obesity)?			1					2				3				4
		10.	Is age 55 or older, has a diagnosis of a chronic disease and has been in an institution 20 years or more?			yes					no
2. COMMUNICATION -- To meet this category:
	a.	Three or more questions must be answered with a 3 or a 4.
				No assis-tance			Prompt-ing/ Struc-turing							Super-vision				Some Direct Assis-tance			Total Assis-tance
	b.	How often does this person:
		1.	Indicate wants by pointing, vocal noises, or signs? ((62)(c) Preverbal Expression pg.2)	1			2							3				4
		2.	Use simple words, phrases short sentences? ((67) Sentences pg.2)	1			2							3				4
		3.	Ask for at least ten things using appropriate names? ((67) Vocabulary pg.1)	1			2							3				4
		4.	Understand simple words, phrases or instructions containing prepositions: i.e., on in behind? ((27) Complex Instructions pg.3)	1			2							3				4
		5.	Speak in an easily understood manner? ((66) Speech pg.1)	1			2							3				4
		6.	Identify self, place of residence, and significant other, ((47) Awareness of Others, pg.3)	1			2							3				4
3. TASK LEARNING SKILLS -- To meet this category:
	a.	Three or more questions must be answered with a 3 or a 4.
				Regu- larly				Often					Some-times				Rarely
	b.	How often does this person:
		1.	Pay attention to purposeful activities for 5 minutes? ((42)(2) Attention pg.3)	1				2					3				4
		2.	Stay with a three-step task for more than 15 mintues? ((42) (5) Attention pg. 3)	1				2					3				4
		3.	Tell time to the hour and understand time intervals? ((33) (b) Time pg. 3)	1				2					3				4
		4.	Count more than 10 objects? ((31) (5) Numbers pg.3)	1				2					3				4
		5.	Do simple addition, subtraction ((31) (6)Numbers pg.3)	1				2					3				4
		6.	Write or print ten words? ((59) (3) Writing pg. 2)	1				2					3				4
		7.	Discriminate shapes, sizes, or colors?	1				2					3				4
		8.	Name people or objects when describing pictures? ((67) (4) Vocabulary pg. 1)	1				2					3				4
		9.	Discriminate between one, many, lot? ((31) (2) Numbers pg. 3)	1				2					3				4
4. PERSONAL/SELF CARE -- To meet this category:
	a.	Question No. 1 must be answered with a 4 or a 5, or
	b.	Question No. 2 must be answered with a 4 or a 5, or
	c.	Questions No. 3 and 4 must be answered with a 4 or a 5?
	NOTE: The yes or no questions are for the purpose of identification of needs to be included in the plan of care. Questions answered yes or no are not part of the scale.
				No Assis-tance				Prompt-ing/ Struc-turing					Super-vision				Some Direct Assis-tance				Total Assis-tance
	d.	With what type of assistance can this person currently:
		1.	Perform toileting functions: i.e., maintain bladder and bowel continence, clean self? etc. ((31)(5) Toilet Training pg. 1)	1				2					3				4				5
			(a) has toileting accidents more than twice a day? ((31)(2) Toilet Training pg. 1)	yes									no
			(b) has toileting accidents at night?	yes									no
			(c) Flushes toilet, pulls up clothes? ((36) Self Care at Toilet pg. 2)	yes									no
		2.	Perform eating/feeding functions: i.e., drinks liquids and eats with spoon or fork, etc? ((28)(3) Use of Table Utensils pg. 1)	1				2					3				4				5
			(a) Feeds self with spoon neatly? ((28)(3) Use of Table Utensils)	yes									no
			(b) Spilling? ((3) (3) Drinking pg. 1)	yes									no
		3.	Perform bathing functions (i.e., bathe, runs bath, dry self, etc.)? ((44)(5) Bathing pg. 2)	1				2					3				4				5
			(a) Washes hands and face with soap? ((39) (40) Washes Hands and Face pg. 2)	yes									no
			(b) Dries hands and face? ((42) Washes Hands and Face pg. 2)	yes									no
			(c) Care for hair, nails, beard?	yes									no
		4.	Dress self completely i.e., including fastening, putting on clothes, etc. ((5) (6) Dressing pg. 2)	1				2					3				4				5
			(a) Dresses upper body, but needs help with fastening?	yes									no
			(b) Dresses self but needs assistance with pulling, or	yes									no
			(c) Putting on most clothing, fastening, shoes? ((50) (3) Dressing (52) Shoes pg. 2)	yes									no
5. MOBILITY -- To meet this category:
	a.	Any one question must be answered with a 4 or a 5.
	NOTE: The yes or no questions are for the purpose of identification of needs to be included in the plan of care. Questions answered yes or no are not part of the scale.
				No Assis-tance					Prompt-ing/ Struc-turing			Super-vision				Some Direct Assis-tance				Total Assis-tance
	b.	With what type of assistance can this person currently:
		1.	Move (walking, wheeling) around environment? ((59) Ambulation pg. 1,(79) Physical Aids pg. 4)	1					2			3				4				5
			(a) Walk with assistive device, person? ((59) Ambulation pg. 1, Physical Aids pg. 4)	yes								no
			(b) Walk on level ground for 50 yards with or without assistive device? ((73, 74, 76) Physical Aids, pg. 4)	yes								no
			(c) Transfer to/from a wheelchair? ((75) Physical Aids pg. 4)	yes								no
		2.	Rise from lying down to sitting positions, sits without support? ((27) Body Balance pg. 1)	1					2			3				4				5
		3.	Turn and position in bed, roll over?	1					2			3				4				5
6. BEHAVIOR -- To meet this category:
	a.	Any one question must be answered with a 3 or a 4.
					Rarely					Some-times			Often				Regu- larly
	b.	How often does this person:
		1.	Engage in self-destructive behavior? ((61) Maladaptive Behavior pg. 4)		1					2			3				4
		2.	Threaten or do physical violence to others? ((52) Maladaptive Behavior pg. 4)		1					2			3				4
		3.	Throw things, damage property, have temper outbursts? ((53, 55) Maladaptive Behavior pg. 4)		1					2			3				4
		4.	Respond to others in a socially unacceptable manner (without undue anger, frustration or hostility)? ((50) Interactions with Others pg. 3)		1					2			3				4
7. COMMUNITY LIVING SKILLS -- To meet this category:
	a.	Any two of questions 2, 5, or 7 must be answered with a 4 or a 5, or
	b.	Three or more of questions 1 through 8 must be answered with a 4 or a 5.
					No Assis-tance					Prompt-ing/ Struc-turing			Super-vision				Some Direct Assis-tance				Total Assis-tance
	c.	With what type of assistance would this person currently be able to:
		1.	Prepare simple foods requiring no mixing or cooking? ((38) Food Preparation pg. 3)		1					2			3				4				5
		2.	Take care of personal belongings, room (excluding vacuuming, ironing, clothes washing/drying, wet mopping)? ((43) Personal Belongings pg. 3)		1					2			3				4				5
		3.	Add coins of various demonima1 nations up to one dollar? ((57) Money Handling pg. 2)		1					2			3				4				5
		4.	Use the telephone to call home, doctor, fire, police?		1					2			3				4				5
		5.	Recognize survival signs/words: i.e., stop, go, traffic lights, police, men, women, restrooms, danger, etc.? ((68) Reading pg. 2)		1					2			3				4				5
		6.	Refrain from exhibiting unacceptable sexual behavior in public? ((63, 64, 65) Maladaptive Behavior pg. 4)		1					2			3				4				5
		7.	Go around cottage, ward, building, without running away, wandering off, or becoming lost? ((56) Sense of Direction pg. 2, (57) Maladaptive Behavior pg. 4)		1					2			3				4				5
		8.	Make minor purchases i.e., candy, soft drink, etc.? ((58, 4) Purchasing pg. 2)		1					2			3				4				5

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-04-8.2 § 4, eff. December 26, 1985.

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