Section 340. Reevaluation of service need and quality management review

A. The comprehensive service plan (CSP).

1. The CSP shall be developed by the case manager in coordination with others involved in the care of the client based on relevant, current assessment data. The CSP process determines the services to be rendered to clients, the frequency of services, the type of service provider, and a description of the services to be offered. All CSPs developed by the case manager are subject to approval by DMAS.

2. The case manager shall be responsible for continuous monitoring of the appropriateness of the client's CSP and revisions to the CSP as indicated by the changing needs of the client. At a minimum, the case manager must review the CSP every three months to determine whether service goals and objectives are being met and whether any modifications to the CSP are necessary.

3. The DMAS staff will review the CSP every 12 months or more frequently as required to assure proper utilization of services. Any modification to the amount or type of services in the CSP must be authorized by DMAS.

B. Review of level-of-care.

1. The case manager must complete an annual comprehensive reassessment, in coordination with the individual, family/caregivers and service providers. If warranted, the case manager will coordinate a medical examination and a mental health evaluation for each waiver client. The reassessment must include an update of the assessment instrument and any other appropriate assessment data.

2. Medical examinations must be completed according to the recommended frequency and periodicity of the EPSDT program.

3. The mental health assessment for clients must reflect the current psychological status (diagnosis) and adaptive level of functioning. A new mental health assessment shall be required whenever the current mental health assessment is no longer reflective of the child's current condition.

C. Documentation required.

The case management agency must maintain the following documentation for review by the DMAS staff for each waiver client:

1. All CSPs, assessment summaries, and supporting documentation completed for the client and retained for a period of not less than six years from each client's last date of service or as provided by applicable state or federal laws; whichever period is longer. Records of minors shall be kept for at least six years after such minor has reached the age of 18 years;

2. All individual providers' ISPs from any provider rendering waiver services to the client and all supporting documentation related to any change in the ISPs;

3. All supporting documentation related to any change in the CSP;

4. All related communication with the providers, client, consultants, DMHMRSAS, CSA, DMAS, DSS, DRS; and others involved in the care of the child; and

5. An ongoing log that documents all contacts made by the case manager related to the waiver client.

6. All supporting documentation developed for the client and retained for a period of not less than six years from each client's last date of service or as provided by applicable state or federal laws, whichever period is longer. Records of minors shall be kept for at least six years after such minor has reached the age of 18 years;

7. An attendance log that documents the date services were rendered and the amount and type of services rendered; and

8. Appropriate progress notes reflecting client's status and, as appropriate, progress toward the goals on the CSP.

Historical Notes

Derived from Volume 24, Issue 02, eff. December 1, 2007.

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.