12VAC30-120 Waivered Services

REGULATIONS

Vol. 29 Iss. 25 - August 12, 2013

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Chapter 120

Fast-Track Regulation

Title of Regulation: 12VAC30-120. Waivered Services (repealing 12VAC30-120-450 through 12VAC30-120-480).

Statutory Authority: § 32.1-325 of the Code of Virginia.

Public Hearing Information: No public hearings are scheduled.

Public Comment Deadline: September 11, 2013.

Effective Date: September 26, 2013.

Agency Contact: Brian McCormick, Regulatory Supervisor, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone [phone], FAX [phone], or email [e-mail].

Basis: Section 32.1-325 of the Code of Virginia grants the Board of Medical Assistance Services the authority to administer and amend the State Plan for Medical Assistance. Section 32.1-324 of the Code of Virginia authorizes the Director of the Department of Medical Assistance Services (DMAS) to administer and amend the Plan for Medical Assistance according to the board's requirements. The Medicaid authority as established by the Social Security Act (42 USC § 1396a) provides governing authority for payments for services.

DMAS initiated this home-based and community-based waiver in concert with 1993 General Assembly action to significantly reform the assisted living (formerly the adult care residence) industry per §§ 63.1-25.1, 63.1-172, and 63.1-173.3 of the Code of Virginia. DMAS derived its authority to operate this waiver from § 1915(b) of the Social Security Act, which permitted Medicaid coverage of these services in assisted living facilities (ALFs) as an alternative to more costly nursing facility care.

Purpose: This regulatory action concerns the assisted living facility program that DMAS implemented in August 1996, which was designed to serve individuals living in community assisted living facilities. In 1993, the General Assembly approved significant legislation to reform the assisted living facility (formerly the adult care residence) industry. The 1993 and 1995 legislative sessions amended § 63.1-25.1 of the Code of Virginia requiring that auxiliary grant (AG) recipients be evaluated by a case manager or other qualified assessor to determine their need for residential care. Section 63.1-173.3 of the Code of Virginia was also amended to require that the uniform assessment instrument be completed upon admission and at subsequent intervals as determined by regulations promulgated by the Board of Social Services for each auxiliary grant resident. Section 63.1-172 of the Code of Virginia was also amended to establish two-tier licensing for adult care residences. Residences were required to offer a level of service to individuals who had physical or mental impairments and who required at least a moderate level of assistance with activities of daily living.

DMAS sought federal approval of a waiver, under the authority of § 1915(c) of the Social Security Act, to provide home-based and community-based services for persons who were determined to be at risk of nursing home placement in the near future but for the provision of the type of care that was provided in an assisted living facility. In 1994, Chapter 965, Item 396 F of the 1994 Acts of Assembly authorized DMAS to seek this waiver to make payments for intensive assisted living services provided to residents of ALFs who were AG recipients. This DMAS waiver was initiated in August 1996.

DMAS assisted living waiver regulations established coverage criteria and payment for two types of assisted living services available to recipients of AG residing in licensed adult care residences: (i) regular assisted living services for those individuals who did not meet the criteria for waiver services but who required at least a moderate level of assistance with activities of daily living, and (ii) intensive assisted living services for those individuals who met the level of care criteria for waiver services.

The DMAS waiver permitted Medicaid reimbursement for regular assisted living services ($3.00 per diem) and intensive assisted living services ($6.00 per diem) using level of care criteria, which was essentially the same as that used in the elderly or disabled (ED) waiver that is now known as the elderly or disabled with consumer direction (EDCD) waiver.

In March of 2000, the Centers for Medicare and Medicaid Services (CMS) declined to renew its approval of this waiver due to concerns about the program's operation thereby withdrawing federal financial participation. This waiver nonrenewal concerned four issues: (i) concern that these individuals be provided their choice of either institutional or home-based and community-based services; (ii) concern that these individuals be reevaluated at least annually; (iii) concern whether the state's licensing and certification standards were being met for services provided in the waiver; and (iv) concern that all facilities covered by § 1616(e) of the Social Security Act comply with the state's requirements for board and care facilities.

In spite of efforts on the part of DMAS to address these concerns, CMS terminated its federal financial participation with the Commonwealth for this waiver. Consequently, DMAS elected to continue the intensive assisted living payments for the few remaining individuals in this waiver under a grandfather provision in the budget. The Commonwealth's funding for this service was discontinued as a result of budget reductions in 2010 (Chapter 874, Item 297 VV of the 2010 Acts of Assembly). Because Medicaid providers are permitted up to one year from the date of service in which to submit their claims for reimbursement, DMAS had to retain operational regulations until June 30, 2011. Subsequent to the passage of this time period, DMAS is initiating this regulatory action to repeal these regulations.

Since this program's enabling federal waiver has been discontinued, there is no more need for these related regulations, so they are being repealed in this action. This action has no effect on the health, safety, or welfare of citizens of the Commonwealth or on the agency.

Rationale for Using Fast-Track Process: CMS denied Virginia any further federal funding for the Assisted Living Services for Auxiliary Grant Individuals waiver program. Also, the General Assembly discontinued funding these additional payments for this program. The termination of both funding sources thereby leaves these regulations as serving no legal purpose. As DMAS had no other options in this matter, the agency determined that repealing the regulations would not be controversial, and appropriate for the fast-track option as permitted by § 2.2-4012.1 of the Code of Virginia.

Issues: There are no disadvantages to the Commonwealth or the agency in this action. In 2010, when the state's funding for this service was terminated, there were only about 1100 individuals for whom DMAS was making this additional payment to the approximately 248 ALFs. The DMAS payments were not a significant source of funding for these facilities. There is no disadvantage to the ALF industry either because they have not received these supplementary payments for a number of years. There are no advantages or disadvantages associated with this regulatory action for the public.

The Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. Pursuant to 2010 Acts of Assembly, Chapter 874, Item 297 VV, the Department of Medical Assistance Services (DMAS) proposes to repeal regulatory language for supplemental payments for regular and intensive assisted living services provided to auxiliary grant recipients.

Result of Analysis. The benefits likely exceed the costs for all proposed changes.

Estimated Economic Impact. These regulations address assisted living services provided through Medicaid to individuals receiving an auxiliary grant. This waiver program was originally implemented in August 1996 with funding from both state and federal sources. In March 2000, the Centers for Medicare and Medicaid Services (CMS) discontinued the federal financial support for this waiver due to concerns about the programs operation. Following CMS's action, this program had been continued with state-only funds. Prior to July 1, 2010, the program provided $3 per day supplemental reimbursement for regular assisted living services and $6 per day for intensive assisted living services from Virginia Medicaid for recipients in addition to the payments provided by the auxiliary grant.¹ However, 2010 Acts of Assembly, Chapter 874, Item 297 VV, terminated the supplemental funding for these services under Medicaid as of July 1, 2010. Because Medicaid providers are permitted up to one year from the date of service in which to submit their claims for reimbursement, operational regulations had been retained until June 30, 2011. Since that time has passed, DMAS proposes to repeal these regulations that are currently obsolete.

In 2010, there were about 1,100 individuals for whom approximately $1.4 million in state only funds were paid to 248 assisted living facilities. However, no significant economic effect, other than removing potentially confusing obsolete language, is expected upon promulgation of these regulations because the funding had already been eliminated as of July 1, 2010. These regulations will simply effectuate the last step of the statutory mandate by removing currently obsolete regulations.

Businesses and Entities Affected. In 2010, when the state's funding for this service was terminated, there were about 1,100 individuals for whom these additional payments were made to approximately 248 assisted living facilities.

Localities Particularly Affected. The proposed regulations apply throughout the Commonwealth.

Projected Impact on Employment. No significant impact on employment is expected upon promulgation of these regulations since the funding for these services had already been eliminated as of July 1, 2010.

Effects on the Use and Value of Private Property. No significant impact on the use and value of private property is expected upon promulgation of these regulations since the funding for these services had already been eliminated as of July 1, 2010.

Small Businesses: Costs and Other Effects. There were approximately 278 providers providing services to auxiliary grant recipients. DMAS believes that most, if not all, are likely to be small businesses, due to the nature of this industry. However, the proposed repeal of these regulations will not impose costs on small businesses upon promulgation since the funding for these services had already been eliminated by the statutory mandate as of July 1, 2010.

Small Businesses: Alternative Method that Minimizes Adverse Impact. The proposed repeal of these regulations will not impose an adverse impact on small businesses upon promulgation since the funding for these services have already been eliminated by the statutory mandate since July 1, 2010.

Real Estate Development Costs. No effect on real estate development costs is expected.

Legal Mandate. The Department of Planning and Budget (DPB) has analyzed the economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Administrative Process Act and Executive Order Number 14 (10). Section 2.2-4007.04 requires that such economic impact analyses include, but need not be limited to, a determination of the public benefit, the projected number of businesses or other entities to whom the regulation would apply, the identity of any localities and types of businesses or other entities particularly affected, the projected number of persons and employment positions to be affected, the projected costs to affected businesses or entities to implement or comply with the regulation, and the impact on the use and value of private property. Further, if the proposed regulation has an adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include (i) an identification and estimate of the number of small businesses subject to the regulation; (ii) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the regulation, including the type of professional skills necessary for preparing required reports and other documents; (iii) a statement of the probable effect of the regulation on affected small businesses; and (iv) a description of any less intrusive or less costly alternative methods of achieving the purpose of the regulation. The analysis presented above represents DPB's best estimate of these economic impacts.

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¹ The assisted living facility rate for auxiliary grant recipients was $1,112 per month in 2010.

Agency's Response to Economic Impact Analysis: The agency has reviewed the economic impact analysis prepared by the Department of Planning and Budget regarding the regulations concerning 12VAC30-120-450 et seq., Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences. The agency concurs with this analysis.

Summary:

The amendments repeal Part VII Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences (12VAC30-120-450 et seq.) that the Department of Medical Assistance Services implemented in August 1996 and was designed to give additional financial support for qualifying individuals living in assisted living facilities under the authority of a federal waiver. The Centers for Medicare and Medicaid Services discontinued this waiver in March 2000 due to concerns about the programs operation. This action is needed in order to repeal these waiver regulations that are no longer operable.

Part VII
Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences (Repealed)

12VAC30-120-450. Definitions. (Repealed.)

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 (ADLs)" means bathing, dressing, toileting, transferring, bowel control, bladder control, and eating/feeding. A person's degree of independence in performing these activities is a part of determining appropriate level of care and services.

"Assessor" means a case manager employed by a public human service agency or other qualified assessor which has a contract with the Department of Medical Assistance Services to perform assessments and authorize service in an adult care residence.

"Assisted living facility" or "facility" means an adult care residence which has been licensed by the Department of Social Services to provide a level of service for adults who may have physical or mental impairments and require at least moderate assistance with the activities of daily living. Within assisted living, there are two payment levels for recipients of an auxiliary grant: regular assisted living and intensive assisted living.

"Auxiliary Grants Program" means a state and locally funded assistance program to supplement the income of a Supplemental Security Income (SSI) recipient or adult who would be eligible for SSI except for excess income and who resides in a licensed adult care residence.

"Case management agency" means a public human service agency having a contract with DMAS to provide case management services to any adult care residence recipient who meets the criteria set forth in Attachment 3.1, Supplement 2 of the State Plan for Medical Assistance (12VAC30-50-470) and which employs or contracts for case management.

"Case manager" means an employee of a public human service agency who is qualified and designated to authorize service in an adult care residence and to perform case management functions, such as the development, implementation, coordination and monitoring of plans of care and completion of the annual reassessment.

"DMAS" or "department" means the Department of Medical Assistance Services.

"DSS" means the Department of Social Services.

"General relief" means money payments and other forms of relief made to eligible persons as established by the local department of social services board in accordance with the rules and regulations of the State Board of Social Services. For purposes of this part, these recipients must reside in a public home for adults in Waynesboro and Manassas.

"Instrumental activities of daily living (IADLS)" means meal preparation, housekeeping, laundry, and money management. A person's degree of independence in performing these activities is a part of determining appropriate level of care and services.

"Individualized service plan" means the written description of actions to be taken by the assisted living facility to meet the assessed needs of the resident. "Intensive assisted living services" means services provided under the Social Security Act, § 1915(c) waiver program, to persons who have dependencies in at least four ADLs, or who have a combination of dependencies in two or more ADLs and are rated as semi-dependent or dependent in a combination of behavior and orientation.

"Licensed health care professional" means a health care professional as defined by § 32.1-162.7 of the Code of Virginia.

"Moderate assistance" means dependency in two or more of the activities of daily living as documented on the uniform assessment instrument. Included in this level of service are recipients who are dependent in behavior pattern (i.e., the recipient exhibits acts detrimental to the life, comfort, safety or property of the recipient or others).

"Qualified assessor" means an entity contracting with DMAS to perform nursing facility preadmission screening or to complete the uniform assessment instrument for a home-based and community-based waiver program, including an independent physician contracting with DMAS to complete the uniform assessment instrument for applicants to adult care residences, or any hospital which has contracted with DMAS to perform nursing facility preadmission screenings. Qualified assessors may only perform the initial assessment or assessments for changes in level of care. Qualified assessors will not have a contract with DMAS to provide case management services for adult care residence recipients which includes the annual reassessment.

"Regular assisted living services" means a level of services provided by licensed adult care residences to persons who have dependencies in two ADLs or behavior but who do not meet the criteria for intensive assisted living.

"Uniform assessment instrument (UAI)" means the department-designated assessment form.

12VAC30-120-460. General coverage and requirements for assisted living services. (Repealed.)

A. Service populations. Two levels of assisted living, regular and intensive assisted living, shall be available to individuals eligible for an auxiliary grant who require assistance in activities of daily living and instrumental activities of daily living, which are above the room, board, and supervision provided by the adult care residence as reimbursed by an auxiliary grant program. Regular assisted living only shall be available to individuals eligible for general relief payments residing in public homes for adults in Waynesboro and Manassas and who meet the program criteria. The individual shall be classified into one of these two levels by the assessor responsible for completing the UAI and authorization of admissions to the adult care residence.

Coverage shall be provided under a state-funded program for individuals who have been determined to require regular assisted living services.

Coverage shall be provided under a waiver of § 1915(c) of the Social Security Act for individuals who have been determined to require intensive assisted living services. This coverage is not available to general relief recipients.

B. Covered services. DMAS shall pay the facility a per diem fee for each recipient authorized to receive assisted living services, based on whether the recipient is authorized for regular or intensive assisted living. Payment of the per diem fee is limited to the days in which the recipient is physically present in the facility.

The facility shall employ or contract with staff who will provide hands-on assistance or supervision with ADLs and IADLs to recipients according to the individual service plan. This plan shall be developed by the facility in accordance with the current needs of the recipient and as specified in 22VAC40-71-170 of the Standards and Regulations for Licensed Adult Care Residences.

The facility shall retain a licensed health care professional as specified in 22VAC40-71-630 J of the Standards and Regulations for Licensed Adult Care Residences except that the records maintained by the facility shall document that the care needs for auxiliary grant recipients authorized to receive intensive assisted living services have been reviewed during an onsite visit at least monthly by a licensed health care professional. The licensed health care professional shall, as appropriate, participate in the development and monitoring of an individualized service plan to meet the resident's service needs.

C. Eligibility requirements. Individuals authorized to receive optional state supplement (auxiliary grant) payments and who meet the criteria for regular or intensive assisted living shall be eligible.

Individuals authorized to receive optional general relief payments, who meet the criteria for regular assisted living, and who reside in public homes for adults in Waynesboro and Manassas shall be eligible.

The department's payment for either regular or intensive assisted living services shall not be reduced by any payment from the individual's income.

The requirements related to spousal income and resource allowances found in § 1924 of the Social Security Act do not apply to those individuals receiving intensive assisted living services under a waiver of § 1915(c) of the Social Security Act.

D. Assessment and authorization of regular or intensive assisted living services.

1. The assessor shall evaluate the individual's functional and medical needs and authorize services to meet those needs pursuant to this part.

2. The assessment shall be completed using the UAI, and authorization for care shall be made based on the following criteria:

a. Regular assisted living. The individual must be dependent in two ADLs or dependent in behavior. The rating of functional dependencies shall be as specified in 22VAC40-745-70 of the Assessment in Adult Care Residences regulations.

b. Intensive assisted living. The individual must be determined to be at risk of nursing facility placement in the absence of home-based and community-based waiver services such as those provided in an assisted living facility and the individual's functional capacity is described by one of the following. The rating of functional dependencies shall be as specified in 12VAC30-60-300 of the State Plan for Medical Assistance (§ 1.1 of Supplement 1 to Attachment 3.1 C:)

(1) Dependent in four or more ADLs;

(2) Dependent in two or more ADLs and has dependencies or semidependencies in a combination of behavior and orientation; or

(3) Semidependent in two or more ADLs and has dependencies in a combination of behavior and orientation.

3. Payment for regular and intensive assisted living services shall only be available for recipients residing in a licensed assisted living facility which has a valid DMAS provider agreement.

4. The assessor shall notify DSS eligibility personnel, upon completion of the UAI, that the recipient has been authorized for regular or intensive assisted living services and shall forward the UAI and authorization forms to DMAS, the facility chosen by the recipient and to the case manager, if case management services have been authorized.

5. The assessor shall give all recipients who have been denied assisted living services written notification that services have been denied and give the recipient the right to appeal the decision pursuant to DMAS Client Appeals Regulations (Part I of 12VAC30-110-10 et seq.). The assessor shall submit to DMAS the UAI, authorization form, and a copy of the notification showing denial of services before reimbursement for the assessment shall be made.

6. The assisted living facility shall forward a copy of the Long-Term Care Preadmission Screening Authorization form, completed by the assessor, and the individualized service plan, completed by the facility, to DMAS for authorization to bill DMAS for regular assisted or intensive assisted living services.

7. A recipient may not receive regular or intensive assisted living services concurrently with any other Medicaid-funded in-home or residential support waiver services authorized under § 1915(c) of the Social Security Act.

8. All authorizations and individualized service plans for assisted living services shall be subject to the approval of DMAS prior to Medicaid payment.

E. Effective date for assisted living payments.

1. DMAS shall pay the facility for services rendered while the recipient is both (i) determined, in accordance with regulations promulgated by DSS, to be eligible for benefits under the auxiliary grants or general relief program and (ii) authorized for a level of assisted living.

2. The assisted living authorization shall be considered effective as of the date the authorization form is signed and dated, except in the following situations:

a. In the case of an emergency placement as defined in regulations promulgated by DSS, the assisted living authorization shall be considered effective as of the date of the emergency placement, provided that the authorization form is signed and dated within seven working days after the date of the emergency placement.

b. In the case of recipients residing in a facility on February 1, 1996, and requiring an initial assessment, the assisted living authorization shall be considered effective, as follows: (i) August 1, 1996, provided that the authorization form is signed and dated on or before August 1, 1996; or (ii) as of whichever date on or after August 1, 1996, can be documented as being the date the recipient required a level of assisted living provided that the authorization form is signed and dated on or before February 1, 1997.

3. In addition to the requirements of subdivisions 1 and 2 of this subsection, in order for assisted living payments to be made to a facility, the assisted living authorization shall be based on a UAI which complies with the requirements of § 63.1-173.3 of the Code of Virginia.

12VAC30-120-470. Conditions and requirements for participating assisted living facilities. (Repealed.)

A. General requirements. Facilities approved for participation shall, at a minimum, perform the following activities:

1. Immediately notify DMAS, in writing, of any changes in the level of care authorized and the individualized service plan which the facility previously submitted to DMAS.

2. Ensure freedom of choice to recipients in seeking medical care from any institution, pharmacy, practitioner, or other facility qualified to perform the service or services required and participating in the Medicaid program at the time the service or services are performed.

3. Ensure the recipient's freedom to reject medical care and treatment.

4. Accept referrals for services only when staff is available to deliver the required services.

5. Provide services and supplies to recipients in the same quality and mode of delivery as provided to the general public.

6. Charge DMAS for the provision of services to recipients in amounts not to exceed the facility's usual and customary charges to the general public.

7. Accept DMAS payment from the first day of the recipient's eligibility.

8. Accept as payment in full the amount established by DMAS.

9. Use program-designated billing forms for submission of charges.

10. Record maintenance and retention requirements.

a. The facility agrees to maintain and keep adequate and verifiable information and records as is necessary to:

(1) Identify and disclose the extent of services, as identified on the uniform assessment instrument, the facility furnishes to recipients;

(2) Comply with the disclosure requirements of Subpart B of 42 CFR Part 455;

(3) Assure proper payment by the DMAS;

(4) Receive payments under the Medicaid program;

(5) Satisfy or secure overpayments, or both, made under the Medicaid program; and

(6) Survive any termination of the provider participation agreement.

b. The facility agrees to furnish the information required to be maintained to the DMAS, the Attorney General of Virginia or his authorized representatives, or the state Medicaid Fraud Control Unit on request and in the form requested. This right of access to facilities and records shall survive any termination of this agreement.

c. Records shall be retained for at least five years from the last date of service or as provided by applicable state laws, whichever period is longer. If an audit is initiated within the required retention period, the records shall be retained until the audit is completed and every adjustment, retraction, exception and appeal is resolved.

d. In the event a facility discontinues operation, DMAS shall be notified in writing of the location and procedures for obtaining stored records for review. The location, agent, or trustee shall be within the Commonwealth of Virginia.

11. Disclose all financial, beneficial, ownership, equity, surety, or other interests it has 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 Medicaid recipients.

12. Hold confidential and use only for authorized DMAS purposes all medical and identifying information regarding recipients served.

13. When ownership of the facility changes, DMAS shall be notified within 15 calendar days of such change. A new DMAS provider agreement shall be required.

B. Requests for participation. Requests for participation must be accompanied with verification of the facility's current licensure from DSS.

C. Facility participation standards. DMAS will contract only with adult care residences licensed to provide assisted living services.

D. Adherence to facility contract and special participation conditions. All adult care residences contracting with DMAS must be in compliance with the DSS licensure requirements for assisted living facilities (22VAC40-71-10 et seq.).

E. Choice of facilities. Recipients eligible for intensive assisted living services shall be informed at the time of the assessment of all available assisted living facilities in the community and shall have the option of selecting the facility.

F. Appeals of adverse actions.

1. A facility shall have the right to appeal adverse action taken against it by DMAS. Adverse action includes, but is not limited to, termination of the provider agreement by DMAS, and retraction of payments from the facility by DMAS for noncompliance with applicable law, regulation, policy or procedure.

2. A facility shall not have the right to appeal to DMAS the following:

a. The criteria for regular assisted living services or for intensive assisted living services;

b. The assignment or nonassignment of a recipient to a particular level of assisted living; or

c. The methodology for calculating the per diem fee paid for regular or intensive assisted living services.

3. Appeals procedure. The administrative appeals procedure shall consist of the following three phases:

a. A reconsideration of the preliminary findings and a written response to the facility by the DMAS division which made the preliminary findings;

b. An informal fact-finding conference held in accordance with the Administrative Process Act with a written decision issued by the Appeals Division; and

c. A formal evidentiary hearing held in accordance with the Administrative Process Act (§ 9-6.14:1 et seq. of the Code of Virginia) with a written decision issued by the DMAS Director.

4. Time frames to request appeals. The facility shall have 15 days from the date of service of the notification of adverse action to request a reconsideration, 30 days from the date of service of the written reconsideration to request an informal fact-finding conference, and 30 days from the date of service of the written informal fact-finding conference decision to request a formal evidentiary hearing. The date of service shall be deemed to be the earlier to occur of the date the notification, reconsideration or decision (i) was mailed to the facility, or (ii) was received by the facility. In the event the notification, reconsideration or decision being appealed was served on the facility by mail, three days shall be added to the applicable 15-day or 30-day period.

G. Responsibility for sharing information. It shall be the facility's responsibility to notify the case manager, DMAS, and DSS in writing within 30 days, or within the time frame of applicable DSS regulations, whichever is shorter, of the occurrence of any of the following circumstances:

1. There is a change in the recipient's functional or cognitive ability which would require a change in the authorized level of care. Temporary changes in a recipient's condition that can be reasonably expected to last less than 30 days do not require a new assessment, authorization, or notification;

2. A recipient dies;

3. A recipient is discharged from the facility; or

4. Other circumstances arise (including hospitalizations) which cause services to cease or be interrupted for more than 30 days.

H. Changes or termination of care. It shall be the assessor's responsibility to authorize changes to a recipient's level of care or to terminate payment for services.

1. The assessor shall communicate in writing to the facility and the recipient any change in level of care or any termination of services. The recipient shall be notified of the right to request a reconsideration by DMAS of any decision that changes the level of care authorized or terminates regular assisted living or intensive assisted living services.

2. If a reconsideration is requested by the recipient, DMAS will review the assessor's recommendation and respond to the individual in writing within 10 days of receipt of the request. If the assessor's decision is upheld, DMAS shall give the recipient the right to appeal the decision pursuant to DMAS' Client Appeals Regulations (Part I of 12VAC30-110-10 et seq.).

3. The effective date of a termination or change in level of services shall be at least 10 days from the date of the notification letter.

I. Suspected abuse or neglect. Pursuant to § 63.1-55.3 of the Code of Virginia, if a participating facility, qualified assessor, or case management agency knows or suspects, or has reason to suspect, that a recipient is being abused, neglected, or exploited, the party having knowledge or suspicion of the abuse/neglect/exploitation shall report this to the local DSS' adult protective services of the county or city wherein the adult resides or wherein the abuse, neglect or exploitation is believed to have occurred.

J. Monitoring of adherence to facility participation standards. The Department of Social Services' Division of Licensing shall be responsible for monitoring each assisted living facility's adherence to licensure standards which provide the basis for DMAS provider participation standards. In addition, DMAS shall periodically conduct audits of the services billed to DMAS and interview recipients to ensure that services are being provided and billed in accordance with DMAS policies and procedures. A facility's noncompliance with DMAS policies and procedures shall result in a written request from DMAS for a corrective action plan which details the steps the facility must take and the length of time permitted to achieve full compliance with DMAS regulations, policies and procedures.

12VAC30-120-480. Reevaluation of service need and utilization review. (Repealed.)

A. The case manager shall be responsible for review of each regular assisted living or intensive assisted living recipient's need for services at least every 12 months, or more frequently as required, to ensure proper utilization of services. The outcome of this review shall be communicated to the DSS eligibility staff, DMAS, the recipient, and the facility where the resident resides.

B. The assisted living facility shall be required to maintain the following documentation for review by the case manager and DMAS staff for each regular assisted living or intensive assisted living resident:

1. All UAIs, authorization forms, and individualized service plans completed for the recipient maintained for a period not less than five years from the recipient's start of care in that facility.

2. All written communication related to the provision of care between the facility and the assessor, case manager, licensed health care professional, DMAS, DSS, the recipient, or other related parties.

3. A log which documents each day that the recipient is present in the facility.

VA.R. Doc. No. R13-2781; Filed July 15, 2013, 5:12 p.m.