Section 303. Preadmission screening criteria for long-term care

12VAC30-60-303. Preadmission screening criteria for long-term care.

A. Functional dependency alone is not sufficient to demonstrate the need for nursing facility care or placement or authorization for community-based care.

B. An individual shall only be considered to meet the nursing facility criteria when both the functional capacity of the individual and his medical or nursing needs meet the following requirements. Even when an individual meets nursing facility criteria, placement in a noninstitutional setting shall be evaluated before actual nursing facility placement is considered.

1. Functional capacity.

a. When documented on a completed state-designated preadmission screening assessment instrument that is completed in a manner consistent with the definitions of activities of daily living and directions provided by DMAS for the rating of those activities, individuals may be considered to meet the functional capacity requirements for nursing facility care when one of the following describes their functional capacity:

(1) Rated dependent in two to four of the Activities of Daily Living, and also rated semi-dependent or dependent in Behavior Pattern and Orientation, and semi-dependent in Joint Motion or dependent in Medication Administration.

(2) Rated dependent in five to seven of the Activities of Daily Living, and also rated dependent in Mobility.

(3) Rated semi-dependent in two to seven of the Activities of Daily Living, and also rated dependent in Mobility and Behavior Pattern and Orientation.

b. The rating of functional dependencies on the preadmission screening assessment instrument must be based on the individual's ability to function in a community environment, not including any institutionally induced dependence. The following abbreviations shall mean: I = independent; d = semi-dependent; D = dependent; MH = mechanical help; HH = human help.

(1) Bathing

(a) Without help (I)

(b) MH only (d)

(c) HH only (D)

(d) MH and HH (D)

(e) Performed by Others (D)

(2) Dressing

(a) Without help (I)

(b) MH only (d)

(c) HH only (D)

(d) MH and HH (D)

(e) Performed by Others (D)

(f) Is not Performed (D)

(3) Toileting

(a) Without help day or night (I)

(b) MH only (d)

(c) HH only (D)

(d) MH and HH (D)

(e) Performed by Others (D)

(4) Transferring

(a) Without help (I)

(b) MH only (d)

(c) HH only (D)

(d) MH and HH (D)

(e) Performed by Others (D)

(f) Is not Performed (D)

(5) Bowel Function

(a) Continent (I)

(b) Incontinent less than weekly (d)

(c) External/Indwelling Device/Ostomy -- self care (d)

(d) Incontinent weekly or more (D)

(e) Ostomy -- not self care (D)

(6) Bladder Function

(a) Continent (I)

(b) Incontinent less than weekly (d)

(c) External device/Indwelling Catheter/Ostomy -- self care (d)

(d) Incontinent weekly or more (D)

(e) External device -- not self care (D)

(f) Indwelling catheter -- not self care (D)

(g) Ostomy -- not self care (D)

(7) Eating/Feeding

(a) Without help (I)

(b) MH only (d)

(c) HH only (D)

(d) MH and HH (D)

(e) Spoon fed (D)

(f) Syringe or tube fed (D)

(g) Fed by IV or clysis (D)

(8) Behavior Pattern and Orientation

(a) Appropriate or Wandering/Passive less than weekly + Oriented (I)

(b) Appropriate or Wandering/Passive less than weekly + Disoriented -- Some Spheres (I)

(c) Wandering/Passive Weekly/or more + Oriented (I)

(d) Appropriate or Wandering/Passive less than weekly + Disoriented -- All Spheres (d)

(e) Wandering/Passive Weekly/Some or more + Disoriented -- All Spheres (d)

(f) Abusive/Aggressive/Disruptive less than weekly + Oriented or Disoriented (d)

(g) Abusive/Aggressive/Disruptive weekly or more + Oriented (d)

(h) Abusive/Aggressive/Disruptive + Disoriented -- All Spheres (D)

(9) Mobility

(a) Goes outside without help (I)

(b) Goes outside MH only (d)

(c) Goes outside HH only (D)

(d) Goes outside MH and HH (D)

(e) Confined -- moves about (D)

(f) Confined -- does not move about (D)

(10) Medication Administration

(a) No medications (I)

(b) Self administered -- monitored less than weekly (I)

(c) By lay persons, Administered/Monitored (D)

(d) By Licensed/Professional nurse Administered/Monitored (D)

(11) Joint Motion

(a) Within normal limits or instability corrected (I)

(b) Limited motion (d)

(c) Instability -- uncorrected or immobile (D)

c. An individual with medical or nursing needs is an individual whose health needs require medical or nursing supervision or care above the level that could be provided through assistance with Activities of Daily Living, Medication Administration, and general supervision and is not primarily for the care and treatment of mental diseases. Medical or nursing supervision or care beyond this level is required when any one of the following describes the individual's need for medical or nursing supervision:

(1) The individual's medical condition requires observation and assessment to assure evaluation of the person's need for modification of treatment or additional medical procedures to prevent destabilization, and the person has demonstrated an inability to self observe or evaluate the need to contact skilled medical professionals;

(2) Due to the complexity created by the person's multiple, interrelated medical conditions, the potential for the individual's medical instability is high or medical instability exists; or

(3) The individual requires at least one ongoing medical or nursing service. The following is a nonexclusive list of medical or nursing services that may, but need not necessarily, indicate a need for medical or nursing supervision or care:

(a) Application of aseptic dressings;

(b) Routine catheter care;

(c) Respiratory therapy;

(d) Supervision for adequate nutrition and hydration for individuals who show clinical evidence of malnourishment or dehydration or have recent history of weight loss or inadequate hydration that, if not supervised, would be expected to result in malnourishment or dehydration;

(e) Therapeutic exercise and positioning;

(f) Routine care of colostomy or ileostomy or management of neurogenic bowel and bladder;

(g) Use of physical (e.g., side rails, poseys, locked wards) and/or chemical restraints;

(h) Routine skin care to prevent pressure ulcers for individuals who are immobile;

(i) Care of small uncomplicated pressure ulcers and local skin rashes;

(j) Management of those with sensory, metabolic, or circulatory impairment with demonstrated clinical evidence of medical instability;

(k) Chemotherapy;

(l) Radiation;

(m) Dialysis;

(n) Suctioning;

(o) Tracheostomy care;

(p) Infusion therapy;

(q) Oxygen.

d. Even when an individual meets nursing facility criteria, provision of services in a noninstitutional setting shall be considered before nursing facility placement is sought.

C. When assessing an individual 21 years of age or younger, the teams who are conducting preadmission screenings for long-term care services shall utilize the Uniform Assessment Instrument as contained in DMAS' Medicaid Memo dated October 3, 2012, entitled "Development of Special Criteria for the Purposes of Pre-Admission Screening," which can be accessed on the DMAS website at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/MedicaidMemostoProviders.

Historical Notes

Derived from Volume 18, Issue 18, eff. June 20, 2002; amended, Virginia Register Volume 30, Issue 08, eff. February 1, 2014.

Statutory Authority

§ 32.1-325 of the Code of Virginia.