A. Long-term care of residents in nursing
facilities will be provided in accordance with federal law using practices and
procedures that are based on the resident's medical and social needs and
requirements. All nursing facility services, including specialized care, shall
be provided in accordance with guidelines found in the Virginia Medicaid
Nursing Home Manual.
B. Nursing
facilities must conduct initially and periodically a comprehensive, accurate,
standardized, reproducible assessment of each resident's functional capacity.
This assessment must be conducted no later than 14 days after the date of
admission and promptly after a significant change in the resident's physical or
mental condition. Each resident must be reviewed at least quarterly, and a
complete assessment conducted at least annually.
C. The Department of Medical Assistance
Services shall periodically conduct a validation survey of the assessments
completed by nursing facilities to determine that services provided to the
residents are medically necessary and that needed services are provided. The
survey will be composed of a sample of Medicaid residents and will include
review of both current and closed medical records.
D. Nursing facilities must submit to the
Department of Medical Assistance Services resident assessment information at
least every six months for utilization review. If an assessment completed by
the nursing facility does not reflect accurately a resident's capability to
perform activities of daily living and significant impairments in functional
capacity, then reimbursement to nursing facilities may be adjusted during the
next quarter's reimbursement review. Any individual who willfully and knowingly
certifies (or causes another individual to certify) a material and false
statement in a resident assessment is subject to civil money
penalties.
E. In order for
reimbursement to be made to the nursing facility for a recipient's care, the
recipient must meet nursing facility criteria as described in
12VAC30-60-300 (Nursing facility
criteria). In order for the additional $10 per day reimbursement to be made to
the nursing facility for a recipient requiring a specialized treatment bed, the
recipient must meet criteria as described in
12VAC30-60-350. Nursing facilities
must obtain prior authorization for the reimbursement. DMAS shall provide the
additional $10 per day reimbursement for recipients meeting criteria for no
more than 246 days annually. Nursing facilities may receive the reimbursement
for up to 82 days per new occurrence of a Stage IV ulcer. There must be at
least 30 days between each reimbursement period. Limits are per recipient,
regardless of the number of providers rendering services. Nursing facilities
are not eligible to receive this reimbursement for recipients enrolled in the
specialized care program.
In order for reimbursement to be made to the nursing facility
for a recipient requiring specialized care, the recipient must meet specialized
care criteria as described in
12VAC30-60-320 (Adult
ventilation/tracheostomy specialized care criteria) or
12VAC30-60-340 (Pediatric and
adolescent specialized care criteria). Reimbursement for specialized care must
be preauthorized by the Department of Medical Assistance Services. In addition,
reimbursement to nursing facilities for residents requiring specialized care
will only be made on a contractual basis. Further specialized care services
requirements are set forth below.
In each case for which payment for nursing facility services
is made under the State Plan, a physician must recommend at the time of
admission, or if later, the time at which the individual applies for medical
assistance under the State Plan, that the individual requires nursing facility
care.
F. For nursing
facilities, a physician must approve a recommendation that an individual be
admitted to a facility. The resident must be seen by a physician at least once
every 30 days for the first 90 days after admission, and at least once every 60
days thereafter. At the option of the physician, required visits after the
initial visit may alternate between personal visits by the physician and visits
by a physician assistant or nurse practitioner.
G. When the resident no longer meets nursing
facility criteria or requires services that the nursing facility is unable to
provide, then the resident must be discharged.
H. Specialized care services.
1. Providers must be nursing facilities
certified by the Division of Licensure and Certification, State Department of
Health, and must have a current signed participation agreement with the
Department of Medical Assistance Services to provide nursing facility care.
Providers must agree to provide care to at least four residents who meet the
specialized care criteria for children/adolescents or adults.
2. Providers must be able to provide the
following specialized services to Medicaid specialized care recipients:
a. Physician visits at least once weekly
(after initial physician visit, subsequent visits may alternate between
physician and physician assistant or nurse practitioner);
b. Skilled nursing services by a registered
nurse available 24 hours a day;
c.
Coordinated multidisciplinary team approach to meet the needs of the
resident;
d. Infection
control;
e. For residents under age
21 who require two of three rehabilitative services (physical therapy,
occupational therapy, or speech-language pathology services), therapy services
must be provided at a minimum of 90 minutes each day, five days per
week;
f. Ancillary services related
to a plan of care;
g. Respiratory
therapy services by a board-certified therapist (for ventilator patients, these
services must be available 24 hours per day);
h. Psychology services by a licensed clinical
psychologist, licensed clinical social worker, licensed professional counselor,
or licensed clinical nurse specialist-psychiatric related to a plan of
care;
i. Necessary durable medical
equipment and supplies as required by the plan of care;
j. Nutritional elements as
required;
k. A plan to assure that
specialized care residents have the same opportunity to participate in
integrated nursing facility activities as other residents;
l. Nonemergency transportation;
m. Discharge planning; and
n. Family or caregiver training.
3. Providers must coordinate with
appropriate state and local agencies for educational and habilitative needs for
Medicaid specialized care recipients who are under the age of 21.
Notes
12
Va. Admin. Code §
30-60-40
Derived from
VR460-02-3.1300, § 2 C, eff. August 1, 1991; amended, Virginia Register
Volume 10, Issue 22, eff. September 1, 1994; Volume 11, Issue 17, eff. July 1,
1995; Volume 12, Issue 16, eff. July 1, 1996; Volume 14, Issue 12, eff. April
1, 1998; Volume 15, Issue 6, eff. January 6, 1999; Volume 20, Issue 19, eff.
July 1, 2004; Volume 22, Issue 22, eff. August 9,
2006.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.