Current through Register Vol.. 38, No. 17, April 11, 2022
who has been approved to receive FIS, CL, or BI waiver services shall have a
unique person-centered individual support plan (ISP) that sets out his unique,
specific needs and the services designed to meet those needs.
1. The ISP shall be collaboratively developed
at the onset of waiver services and redeveloped, at a minimum, annually by the
support coordinator with the individual and the individual's family/caregiver,
as appropriate, other providers, consultants as may be needed, and other
interested parties at the individual's discretion.
2. The support coordinator shall be
responsible for continuously monitoring the appropriateness of the individual's
services and making timely revisions to the ISP as indicated by the changing
needs of the individual.
modification to the amount or type of services in the ISP shall be service
authorized by DMAS or its designee.
4. The support coordinator shall monitor the
providers' plans for supports to ensure that all providers are working toward
the desired outcomes with the individuals supported.
5. Support coordinators shall be required to
conduct and document evidence of monthly onsite visits for all individuals
enrolled in the DD Waivers who are residing in VDSS-licensed assisted living
facilities or approved adult foster care homes.
6. Support coordinators shall conduct and
document a minimum of quarterly face-to-face visits to all other individuals
with at least one visit annually occurring in the home.
7. All requests for increases in DD waiver
services shall be reviewed by the support coordinator. The support coordinator
shall ensure that the request is based on the individual's demonstrated need
for the increased service, as documented by appropriate assessment criteria and
a written plan for supports, and that those services are necessary to promote
the individual's health, safety, and welfare in the community and can be safely
and cost effectively provided in the community.
8. Support coordinators shall provide an
individual and the family/caregiver, as appropriate, with a copy of the
Providers shall develop and keep updated, to include changing needs, a plan for
supports for every individual supported. The contents of the plan for supports
shall at a minimum contain the items specified in 12VAC30-122-120
A 10 g.
Services that are exempt from provider plans for supports requirements can be
found in each service's specific regulation section.
Reevaluation of service need.
1. At a minimum, the support coordinator
shall review the ISP quarterly to determine whether the individual's desired
outcomes and support activities are being met and whether any modifications to
the ISP are necessary. The results of such reviews shall be documented, signed,
and dated in the individual's record even if no change occurred during the
review period. This documentation shall be provided to DMAS and DBHDS upon
Components of annual
person-centered plan review.
a. The support
coordinator shall complete a reassessment annually, at a minimum, in
coordination with the individual and the individual's family/caregiver, as
appropriate, providers, and others as desired by the individual. The
reassessment shall be signed and dated by the support coordinator and shall
include an update of the level of care (VIDES) and personal profile, risk
assessment, and any other appropriate assessment information. "Risk assessment"
means an assessment used to determine areas of high risk of danger to the
individual or others based on the individual's serious medical or behavioral
factors and shall be used to plan risk mitigating supports for the individual
in the individual support plan.
The ISP shall be revised as appropriate for consistency with this reassessment.
If this annual level of care reassessment demonstrates that the individual no
longer meets waiver requirements, the support coordinator shall inform DMAS and
DBHDS that the individual must be terminated from waiver services.
A medical examination shall be completed
in accordance with 12VAC30-122-180
and, for adults, as needed
and screenings for children ages birth to 21 years shall be completed according
to the recommended frequency and periodicity of the EPSDT program ( 42 CFR
and 12VA C30-50-130).
new psychological or other diagnostic evaluation shall be required whenever the
individual's functioning has undergone significant change, such as
deterioration of abilities that is expected to last longer than 30 days, and is
no longer reflective of the past evaluation. "Significant change" means a
change in an individual's condition that is expected to last longer than 30
calendar days but shall not include short-term changes that resolve with or
without intervention, a short-term acute illness or episodic event, or a
well-established, predictive, cyclical pattern of clinical signs and symptoms
associated with a previously diagnosed condition where an appropriate course of
treatment is in progress.
psychological or other diagnostic evaluation shall be completed by a qualified
examiner, as defined in this subdivision, and reflect the current diagnosis,
adaptive level of functioning, and presence of a functional delay that arose
during the developmental period. "Qualified examiner" means a credentialed
professional, for example a licensed physician, licensed psychologist, or
licensed therapist, who is practicing pursuant to the requirements and limits
of his license.
g. The individual
shall be allowed to select other entities, either persons or organizations, at
his discretion to participate in the annual review of his person-centered