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Pre-Admission Screening

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June 09, 2022, 05:13 EDT

Chapter 4: HCBS Waivers, PACE and Nursing Facilities

Updated: 10/25/2021

GENERAL SCOPE OF THE SCREENING PROCESS FOR MEDICAID-FUNDED LONG-TERM SERVICES AND SUPPORTS (LTSS)

The State Code of Virginia. § 32.1-330. Long-term services and supports screening (LTSS) required, states that  every individual who applies for or requests community or institutional long-term services and supports as defined in the state plan for medical assistance services: may choose to receive services in a community or institutional setting; shall be afforded the opportunity to choose the setting and provider of long-term services and supports; and shall be screened prior to admission to such community or institutional long-term services and supports to determine the need for long-term services and supports, including nursing facility services as defined in the state plan for medical assistance services. The type of long-term services and supports screening performed shall not limit the long-term services and supports settings or providers for which the individual is eligible.

 

Entities authorized to conduct Screenings are local Departments of Social Services (LDSS), local Departments of Health (LDH), hospitals and nursing facilities.  DMAS contracts with the Virginia Department of Health (VDH) and Department for Aging and Rehabilitation Services (DARS), and hospitals to conduct Screenings for individuals.  Community-based Screening teams (CBTs) shall consist of members who are employees of, or contracted with, VDH and/or the local department of social services (LDSS).  All hospitals, which includes acute care hospitals, rehabilitation hospitals, and rehabilitation units in acute care hospital, are to assign staff who are responsible for conducting and submitting the completed Screening.  Nursing facilities shall appoint qualified staff for NF Screening teams.

 

The Screening for Medicaid LTSS is a process to:

 

  • Evaluate the functional, medical or nursing, and social needs of each individual believed to be in need of or at risk of NF admission (42 CRF 441.302 State Assurances), and needing services within 1 month or less;

 

  • Analyze specific services and supports that the individual needs (42 CFR 441.302);

 

  • Evaluate whether a service or a combination of existing home and community-based services (HCBS) is available to meet the individual’s needs by applying existing criteria for NF and HCBS, including the Commonwealth Coordinated Care Plus (CCC Plus) Waiver and the Program of All-Inclusive Care for the Elderly (PACE);

 

  • Provide the individual with the choice of home and community-based or NF services for which the individual qualifies; and

 

  • Conduct an additional Screening for individuals who have selected NF services to identify individuals with any suspected or known diagnosis of mental illness (MI), intellectual disability (ID) or a related condition (RC) who should be evaluated through the “Preadmission Screening and Resident Review” (PASRR) process. A RC is a condition that is similar to a disability (e.g., Cerebral Palsy, Down Syndrome, anoxia at birth, Multiple Sclerosis, paraplegia, intractable seizures, BSpina Bifida, congenital blindness or deafness, Muscular Dystrophy etc.). Federal regulations require anyone being admitted to a Medicaid certified NF with any suspected or known MI, ID, or RC be evaluated through the PASRR process.

 

The Virginia Uniform Assessment Instrument (UAI) is the standardized multidimensional assessment instrument used in Virginia for assessing an individual’s physical health, mental health, psycho/social and functional abilities, and medical or nursing needs. This instrument is used by many agencies across the Commonwealth for a variety of purposes. It is also used in the Medicaid LTSS Screening and is one of several forms in the Screening packet, which must be completed for individuals to determine eligibility for the following LTSS:

 

(NOTE: The Medicaid LTSS Screening encompasses more documents than the UAI.)

 

The following requires a LTSS Screening to determine level of care needs for program enrollees:

 

  • NF (to include specialized care NF, long-stay hospital, and  LTSS offered in a NF, often referred to as custodial care),

 

  • CCC Plus Waiver and CCC Plus Waiver with Private Duty Nursing (PDN), or

 

  • PACE.

 

DMAS Resource Website for Screening for LTSS: https://www.dmas.virginia.gov/for-providers/long-term-care/programs-and-initiatives/screening/, including FAQs, and training requirements for LTSS Screeners.

Definitions (PAS)

"Activities of daily living" or "ADLs" means personal care tasks such as bathing, dressing, toileting, transferring, and eating or feeding. An individual's degree of independence in performing these activities is a part of determining appropriate level of care and service needs.

“Acute care hospital” or “Hospital” means an acute care hospital, a rehabilitation hospital, a rehabilitation unit in an acute care hospital, or a psychiatric unit in an acute care hospital.

 

"Adult" means a person age 18 years or older who may need Medicaid-funded long-term services and supports (LTSS) or who becomes eligible to receive Medicaid-funded LTSS. (Private Duty Nursing services begin at age 21 for adults in the CCC Plus Waiver.)

"Appeal" means the processes used to challenge actions regarding services, benefits, and reimbursement provided by Medicaid pursuant to 12VAC30-110-10 et seq. and 12VAC30-20-500 et seq.

"At risk" means the need for the level of care provided in a hospital or nursing facility when there is reasonable indication that the individual is expected to need the services within the next 30 days in the absence of home or community-based services.

"Child" means a person up to the age of 18 years who may need Medicaid-funded LTSS or who becomes functionally eligible to receive Medicaid-funded LTSS. (Private Duty Nursing services begin at age 21 for adults in the CCC Plus Waiver.)

"Choice" means the individual is provided the option of either the Commonwealth Coordinated Care Plus Waiver , the Program of All-inclusive Care for the Elderly (PACE), if available or appropriate, or institutional services and supports, after the individual has been determined likely to need LTSS.

“Commonwealth Coordinated Care Plus Program” or “CCC Plus Program” is a

Medicaid program that provides LTSS through a managed care approach. The program addresses medical, behavioral, and substance use disorder conditions.  Services may be provided in the community or in institutional settings. Eligible Medicaid members who have long-term service and support needs are required to participate in the CCC Plus program.

“Commonwealth Coordinated Care Plus Waiver” or “CCC Plus Waiver” [1915 (c)] provides long-term services and supports in the home and community rather than in a nursing facility (NF) or other specialized care medical facility.

 

"Communication" means all forms of sharing information and includes oral speech and augmented or alternative communication used to express thoughts, needs, wants, and ideas, such as the use of a communication device, interpreter, gestures, and picture/symbol communication boards.

"Community-based team" or "CBT" means (i) a registered nurse, nurse practitioner (ii) a social worker or other assessors designated by DMAS; and (iii) a physician. The CBT members are employees of, or contracted with, the Virginia Department of Health or the local department of social services.  The authorization or denial for Medicaid LTSS (DMAS-96 form) must be signed and attested to by the screener(s) and a physician (or the nurse practitioner or physician’s assistant working with the physician).

 

“CSB” means a local Community Services Board

"DARS" means the Virginia Department for Aging and Rehabilitative Services.

"Day" means calendar day unless specified otherwise.

"DBHDS" means the Virginia Department of Behavioral Health and Developmental Services.

"DMAS" means the Department of Medical Assistance Services.

"DMAS designee" means the public or private entity with a contract with the Department of Medical Assistance Services to complete Medicaid LTSS screenings pursuant to § 32.1-330 of the Code of Virginia when a community-based, hospital or nursing facility LTSS Screening team cannot complete LTSS Screenings within the required 30 days of the  LTSS Screening request date.

"Electronic Medicaid LTSS Screening" or " eMLS" means the DMAS electronic record system used by LTSS screening entities to record results from LTSS screenings pursuant to § 32.1-330 of the Code of Virginia.

"Face-to-face" means an in-person meeting with the individual seeking Medicaid-funded LTSS.

"Feasible alternative" means a range of services that can be provided in the community via waiver or PACE, for less than the cost of comparable institutional care, in order to enable an individual to continue living in the community.

“Functional capacity” means the degree of independence that an individual has in performing ADLs, mobility, joint motion, medication administration, and in relation to behavior and orientation as measured on the UAI and as used as a basis for differentiating levels of LTSS.

“Functional eligibility” means. the individual met criteria used for determining whether an individual needs nursing facility level of care.  Functional eligibility is separately assessed from Medicaid financial eligibility.   

“Home and community-based services (HCBS)” means community-based waiver services i.e. the Commonwealth Coordinated Care Plus (CCC Plus) waiver or the Program of All-Inclusive Care for the Elderly (PACE).

 "Home and community-based services provider" means a provider or agency enrolled with Virginia Medicaid to offer services to individuals eligible for the CCC Plus Waiver or PACE.

"Home and community-based services waiver," “HCBS”, or "waiver services" means the range of community services and supports, approved by the Centers for Medicare and Medicaid Services (CMS) pursuant to § 1915(c) of the Social Security Act to be offered to individuals as an alternative to institutionalization.

"Hospital team" means persons designated by the hospital who are responsible for conducting and submitting the Medicaid LTSS Screening documents for inpatients to eMLS.  The authorization or denial for Medicaid LTSS (DMAS-96 form) must be signed and attested to by the screener(s) and a physician.

"Inpatient" means an individual who has a physician's order for admission to an acute care hospital, rehabilitation hospital, or a rehabilitation unit in an acute care hospital and shall not apply to outpatients, patients in observation beds, and patients of the hospital's emergency department.

“Level of Care” or “LOC” means the formal designation used when describing a person’s eligibility for Medicaid-funded, nursing facility care. It is also used when describing someone’s eligibility to receive long-term services and supports at-home from providers paid by Medicaid. Documentation of needed level of care must include: a summary of the screener’s direct observations, summary of the screener’s professional judgments and conclusions that provide the basis for the judgments and conclusions that substantiate the Level of Care determination and whether the individual qualifies for Medicaid LTSS.

"Local department of social services" or "LDSS" means the entity established under § 63.2-324 of the Code of Virginia by the governing city or county in the Commonwealth.

"Local health department" or "LHD" means the entity established under § 32.1-31 of the Code of Virginia.

"Long-term services and supports" or "LTSS" means a variety of services that help individuals with health or personal care needs and ADLs over a period of time that can be provided in the home, the community, or nursing facilities.

Long-Term Services and Supports (LTSS) Screening” or “LTSS Screening” means the face-to-face process to (i) evaluate the functional, medical or nursing, and social support needs and at-risk status of individuals referred for certain long-term services requiring nursing eligibility; (ii) assist individuals in determining what specific services the individual needs; (iii) evaluate whether a service or a combination of existing community services are available to meet the individual’s needs; and (iv) provide a list to individuals of appropriate providers for Medicaid-funded nursing facilities, PACE plan services or the Commonwealth Coordinated Care Plus waiver for those individuals who meet nursing facility level of care. Individuals enrolled in the CCC Plus managed care program will have the list provided by the MCO in which they are enrolled.

 

“Long-Term Services and Supports (LTSS) Screening Team” means the staff assigned to the hospital screening team, community-based team (CBT), or nursing facility LTSS team, to perform and submit screenings pursuant to § 32.1-330 of the Code of Virginia.

 

“Managed Care Organization,” or "MCO" means those health plans participating in the CCC Plus program and that are a party to a contract with DMAS.

"Medicaid" means the program set out in the 42 USC § 1396 and administered by the Department of Medical Assistance Services consistent with Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia.

“Medical or nursing need” means (i) the individual’s condition requires observation and assessment to ensure evaluation of needs due to an individual’s inability for self-observation or evaluation; (ii) the individual has complex medical conditions that may be unstable or have the potential of instability, or (iii) the individual requires at least one ongoing medical or nursing service.

"Medicare" means the Health Insurance for the Aged and Disabled program as administered by the Centers for Medicare and Medicaid Services pursuant to 42 USC 1395ggg.

  “Minimum Data Set” or “MDS” means the assessment form used by nursing facilities, as federally required, for the purpose of documenting ongoing level of care required for all of the NF’s residents.

"Nursing facility" or "NF" means any nursing home as defined in § 32.1-123 of the Code of Virginia.

“Nursing facility LTSS screening team” means nursing facility staff trained and certified in the use of the LTSS screening tools who are responsible for performing and submitting LTSS screenings for individuals who apply for or request LTSS while receiving skilled nursing services in a setting not covered by Medicaid and after discharge from a hospital. Nursing facility LTSS screening staff must include at least one registered nurse and a certifying physician.  The authorization or denial for Medicaid LTSS (DMAS-96 form) must be signed and attested to by the screener(s) and a physician.

"Ongoing" means continuous medical or nursing needs that shall not be temporary.

"Other assessor designated by DMAS" means an employee of the local department of social services holding the occupational title of family services specialist or an employee of a DMAS designee.

"Private pay individual" means individuals who are not eligible for Medicaid or not expected to become financially eligible for Medicaid and have alternate payment sources that will pay 100 percent for care or services (this can include private insurance, Tricare, Medicare, etc.).

"Program of All-Inclusive Care for the Elderly" or "PACE" means the community-based service pursuant to CFR 42 §460.2 through 210 and § 32.1-330.3 of the Code of Virginia. PACE is an array of services available to individuals 55 or older, eligible for Medicaid, Medicare or are private-pay status individuals living in a PACE service area.  The program provides all-inclusive care, including medical and supportive care that enable the individual to live independently while meeting nursing home criteria.  All-inclusive services include coverage for prescription drugs, physician and dental care, transportation, home care, checkups, hospital visits, and NF stays when necessary.

"Referral for LTSS screening" means information obtained from an interested person or other third party having knowledge of an individual who may need Medicaid-funded LTSS and may include, for example, a physician, PACE provider, service provider, family member, or neighbor who is able to provide sufficient information to enable contact with the individual.

"Representative" means a person who is legally authorized to make decisions on behalf of the individual.

"Request date for LTSS screening" or "request date" means the date (i) that an individual, the individual's representative, an Adult Protective Services (APS) worker, Child Protective Services (CPS) worker, physician, or the managed care organization (MCO) (health plan)  contacts the LTSS screening entity in the jurisdiction where the individual resides asking for assistance with LTSS or, (ii) for hospital inpatients, that a physician orders case management consultation or a hospital's case management service determines the need for LTSS upon discharge from the hospital.

"Request for LTSS screening" means (i) communication from an individual, an emancipated child, individual's representative, Adult Protective Services (APS) worker, Child Protective Services (CPS) worker, physician, managed care organization (MCO) or CSB support coordinator, expressing the need for LTSS, or (ii) for hospital inpatients, a physician order for determination of the need for LTSS upon discharge from a hospital.

"Residence" means the location in which an individual is living, e.g., an individual's private home, apartment, assisted living facility, nursing facility, jail/correctional facility.

"Screening entity” or “Screening organization means the employer of the hospital LTSS screening team, community-based LTSS Screening team (CBT), or nursing facility LTSS Screening team responsible for performing screenings pursuant to § 32.1-330 of the Code of Virginia.

 “Services facilitator" means a DMAS-enrolled provider, a DMAS-designated entity, or a person who is employed or contracted by a DMAS-enrolled services facilitator that is responsible for supporting the individual and the individual's family/caregiver or employer of record (EOR), as appropriate, by ensuring the development and monitoring of the consumer-directed (CD) services plans of care, providing employee management training, and completing ongoing review activities as required by DMAS for consumer-directed (CD) personal care and respite services. “Services facilitator” shall be deemed to mean the same thing as “consumer-directed services facilitator”.

"Significant change in condition" means a change in an individual's condition that is expected to last longer than 30 days and shall not include (i) short-term changes that resolve with or without intervention; (ii) a short-term illness or episodic event; or (iii) a well-established, predictive, cyclic pattern of clinical signs and symptoms associated with a previously diagnosed condition where an appropriate course of treatment is in progress.

“Skilled Care” means care provided by a registered nurse over a limited period of time resulting in the potential that the individual is able to function independently.  Skilled care includes rehabilitation services, observation during periods of acute or unstable illness; administration of intravenous fluids, enteral feedings, and intravenous or intramuscular medications; short-term bowel and bladder retraining; and changing of sterile dressings.

"Submission" means the transmission of the screening findings via the electronic portal for LTSS screenings (commonly called eMLS).

"Uniform Assessment Instrument" or "UAI" means the standardized multidimensional assessment instrument that is completed by the LTSS screening team that assesses an individual's physical health, mental health, psycho/social and functional abilities, and medical or nursing needs used to determine if the individual meets the nursing facility level of care.

"VDH" means the Virginia Department of Health.

Populations to be Screened for Medicaid-Funded LTSS (PAS)

A face-to-face Screening and observation must be performed for individuals who are Medicaid members or are applying for Medicaid, and may need LTSS.  In addition, any individual who requests to receive a LTSS Screening and is not already receiving Medicaid LTSS, must be screened.  LTSS Screenings may occur in the community, for inpatients in a hospital, or for individuals admitted to a NF for skilled care directly from a hospital, when Medicaid is not a payment or potential payment source at admission, but who may have a change in Medicaid financial status AND need LTSS.  The LTSS Screening is used to determine if the individual meets the LOC necessary for the CCC Plus Waiver, PACE or NF placement.

All requests for LTSS Screening shall be honored regardless of the financial or functional capacity of the individual to be screened.  Being a Medicaid member or application for Medicaid is not a requirement to receive a LTSS Screening.  No individual shall be denied a Screening if it is requested, even if a previous Screening indicated that they did not meet the LOC criteria. 

POPULATION EXCLUSIONS AND SPECIAL CIRCUMSTANCES FOR MEDICAID-FUNDED LTSS SCREENING

Private Pay Individuals

 

  • LTSS Screeners are not required to screen private pay individuals being admitted to NFs who are not expected to apply for Medicaid and need LTSS. . 

 

  • Hospitals are required to conduct a screening for all individuals who are Medicaid members, pending Medicaid members or persons likely to become financially eligible for Medicaid after admission to a NF. Hospitals shall not be required to initiate a Screening for inpatients who are determined by the hospital team to be private pay individuals and are not anticipated to be financially eligible for Medicaid.  However, anytime an inpatient or authorized representative requests a Screening, a Screening must be conducted.

 

  • CBTs are not required to perform a Screening for individuals who are private pay or are not anticipated to be financially eligible for Medicaid.  However, anytime an individual living in the community who is not already receiving Medicaid LTSS requests a Screening, a Screening must be conducted.

 

  • If a private pay individual (or person with 100% alternate forms of payment excluding Medicaid) is admitted for SNF services but later becomes Medicaid eligible AND needs LTSS, the NF will complete the Medicaid LTSS Screening per state guidelines.  The NF LTSS Screeners (including a registered nurse) and a NF physician must attest to their signature on the Medicaid LTSS authorization form regarding authorization or non-authorization for LTSS.  

 

  • If a private pay individual (or person with 100% alternate forms of payment excluding Medicaid) chooses a NF for services and is admitted directly to an NF for LTSS but later becomes Medicaid eligible, the NF will complete the Minimum Data Set (MDS) assessment per federal guidelines and a NF physician will certify whether the individual meets the NF LOC criteria.  

 

  • All individuals, private pay or not, entering the PACE program must be Screened.

 

Hospice

 

  • Individuals enrolled in hospice care or who are being admitted to a NF for hospice care are exempt from the Screening for Medicaid LTSS.  For example: if an individual enrolled in hospice enters a NF and remains under the hospice benefit, a Screening for Medicaid LTSS is not required for the individual to be enrolled for  NF services. If an individual converts from hospice status to NF LTSS (custodial care) status, the MDS is completed by the NF and a NF physician must certify that the individual meets NF LOC criteria.

 

 

Out-of-State Residents

 

  • For individuals who reside out-of-state and wish direct admission to a NF in Virginia, a LTSS Screening is not required.  The admitting NF is responsible for ensuring that the individual meets the established criteria for NF placement and meets federal requirements for MI, ID or RC screening and if needed, evaluation and determination of specialty services (PASRR: See Level I and Level II section of this Chapter.)  Note: Virginia cannot impose the state’s LTSSLTSS Screening requirements on other states.

 

  • If a person from out of state is admitted for SNF services but later becomes Virginia Medicaid eligible AND needs LTSS (or is already a Virginia Medicaid member admitted for SNF but later needs LTSS), the NF will complete the Medicaid LTSS Screening per state guidelines.  The NF LTSS Screeners and a NF physician must attest to their signature on the Medicaid LTSS authorization form regarding authorization or non-authorization for LTSS.  

 

  • For individuals who reside out-of-state and wish to enroll into the CCC Plus Waiver or PACE, the CBT in the Virginia locality in which the individual will reside must complete a LTSSLTSS Screening once the individual relocates to Virginia.

 

  • Out-of-state hospitals and NFs shall not be required to perform a LTSS Screening for residents of the Commonwealth who are inpatients. For Virginia residents who receive Virginia Medicaid and who may receive out-of-state acute care hospitalization, from a “border” state hospital close to their homes (i.e., NC, TN, WV, DC, or MD), and who returns to Virginia for care either to their home or to a NF, the following procedure applies:
    • Medicaid LTSS Screening shall not be required for individuals who transfer directly into a NF in the Commonwealth from an out-of-state hospital or NF.
    • If the individual chooses to apply for CCC Plus Waiver or PACE or requests a LTSS Screening (either the individual, the individual's representative or others as defined and allowed), then the individual shall be screened upon discharge from the out-of-state hospital or NF by the CBT serving the locality in which the individual resides or relocates (once the individual relocates to Virginia).

Veterans Administration Medical Center or Other Military Hospital Facility

 

  • LTSS Screenings shall not be required for individuals who transfer directly to a NF in the Commonwealth from a veterans’ or military hospital or Veterans’ Administration Medical Center. 
  • If a person from a veterans’ or military hospital or medical center is admitted for SNF services but later becomes Virginia Medicaid eligible AND needs LTSS (or is already a Virginia Medicaid member admitted for SNF but later needs LTSS), the NF will administer the Medicaid LTSS Screening per state guidelines.  The NF LTSS Screeners and a NF physician must attest to their signature on the Medicaid LTSS authorization form regarding authorization or non-authorization for LTSS. 
  • Individuals seeking CCC Plus Waiver or PACE may, upon discharge from a Veterans’ Administration Medical Center or military hospital, receive a referral to the CBT serving the locality in which the individual resides, and be Screened by the CBT once the individual has relocated.

 

DBHDS Facilities

 

  • Individuals residing in state owned/operated facilities by the Department of Behavioral Health and Developmental Services (DBHDS) who seek direct admission to a Virginia NF shall not be required to have a LTSS Screening. 

 

  • If a person transitioned from a DBHDS facility is admitted for SNF services but later becomes Virginia Medicaid eligible AND needs LTSS (or is already a Virginia Medicaid member admitted for SNF but later needs LTSS), the NF will administer the Medicaid LTSS Screening per state guidelines.  The NF LTSS Screeners and a NF physician must attest to their signature on the Medicaid LTSS authorization form regarding authorization or non-authorization for LTSS. 

 

  • Individuals residing in state owned/operated facilities by DBHDS that need or request a LTSS Screening for a CCC Plus Waiver or PACE shall be referred, upon discharge from the DBHDS facility, to the CBT serving the locality in which the individual resides and be screened by the CBT once the individual has relocated.

Requirements for Performing a Screening for Medicaid-Funded LTSS (PAS)

DMAS, in partnership with VDH, Virginia Department of Social Services (VDSS), DARS, hospitals, and NFs within the Commonwealth, are providing the following guidance to assist LTSS Screeners in understanding their roles and responsibilities in the LTSS Screening process. 

 

  • Who May Request or Refer an Individual for a Screening:

 

  • Request for an adult LTSS Screening in the community: means communication from an individual, the individual's representative, an Adult Protective Services (APS) worker, the individual’s physician, a health plan, or CSB support coordinator expressing the need for LTSS.  For individuals residing in NF LTSS who do not have a LTSS Screening, the person(s) planning discharge for the individual may request a CBT to conduct a LTSS Screening to enable the individual to enroll in CCC Plus Waiver or PACE.
  • Request for children’s LTSS Screening in the community: the request for a LTSS Screening of a child residing in the community shall initiate from either the parent, legal guardian, the entity having legal custody of that child, an emancipated child, a child’s physician, the child’s health plan , a Child Protective Services (CPS) worker or CSB support coordinator having an interest in the child.
  • Request for a hospital inpatient LTSS Screening (adult or child): means a physician’s order for case management consultation or determination of the need for LTSS upon discharge from the hospital.  In addition, if a direct request for a LTSS Screening is made by the individual, the individual's representative, parent or legal guardian, entity having legal custody, the health plan, CSB support coordinator, APS/CPS worker, or emancipated child, a LTSS Screening shall be conducted.
  • Request for a NF LTSS Screening (adult or child): means a physician’s order for case management consultation or determination of the need for LTSS upon level of care change from skilled (including rehabilitation services)  to HCBS or LTSS (custodial care) within the nursing facility.  In addition, if a direct request for a LTSS Screening is made by an individual receiving skilled (including rehab) care or by the individual's representative, parent or legal guardian, entity having legal custody, the health plan care coordinator, CSB support coordinator, or APS/CPS worker, a LTSS Screening shall be conducted.
  • Referral for a LTSS Screening means information obtained from an interested person or other third-party having knowledge of an individual who may need Medicaid-funded LTSS and may include a consulting physician, PACE provider, service provider, family member, neighbor or other person who is able to provide sufficient information to enable contact with the individual.  A referral results in a LTSS Screening, when the individual (or individual’s authorized representative) is contacted by the LTSS Screening Team and agrees to participate in the LTSS Screening process. 

 

  • An individual shall have the right to refuse to participate in the LTSS Screening process except for situations when a court has issued an order for a LTSS Screening.  Any individual refusing to participate must be informed that Medicaid support for services cannot be considered if the LTSS Screening is not completed.

 

  • The individual shall be permitted to have another person or persons present at the time of the LTSS Screening. The LTSS Screening team shall determine the appropriate degree of participation and assistance given by the other person to the individual during the LTSS Screening and will accommodate the individual’s preferences to the extent feasible.

 

  • Observe “face-to-face” the individual's ability to perform ADLs, as appropriate, according to 12VAC30-60-303, consider the individual’s (or his representative’s) communication or responses to questions, and document the person’s functional capacity.

 

  • Consider services and settings that may be needed by the individual in order for the individual to safely perform ADLs.

 

  • Observe “face-to-face,” assess, identify, and report the individual's medical, nursing, and functional abilities.  This information shall be used to ensure accurate and comprehensive evaluation of the individual's need for modification of treatment or additional medical procedures or services to prevent destabilization even when an individual has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals.

 

  • Determine if the individual is “at-risk for institutionalization.”  “At-risk for institutionalization” means that without HCBS the individual would be at-risk of admission to a NF or hospital, within 30 days; however, it does not mean that an individual must be placed in one of these settings.  Results are documented in the case summary box (found on the DMAS-P98 UAI B in  eMLS) and on the DMAS-97 when one of the following conditions are met:

 

        • The individual has been cared for in the home prior to the LTSS Screening and written evidence is available demonstrating: a deterioration in the individual’s health care condition, a significant change in condition, or a change in available supports preventing former care arrangements from meeting the individual’s needs; or

 

        • There has been no significant change in the individual’s condition or available support, but evidence is available that demonstrates that the individual’s functional and medical or nursing needs are not being met.

 

Examples of evidence for the items above may be, but shall not be limited to, recent hospitalizations, attending physician documentation, and/or reported findings from medical or social services programs such as APS, CPS, and CSBs.

 

  • Assess the community resources available to meet the needs of the individual (i.e. immediate family, other relatives, neighbors, community services, and other supports in the continuum of LTSS) and document the findings.  Screeners can enter this information into  eMLS, UAI-A and B.

 

  • Assist individuals and authorized representatives in determining the most appropriate means of meeting the needs of the individual. Use a person-centered approach when obtaining information from the individual being screened. The individual’s needs, wants and desires must be considered when planning for LTSS. The LTSS Screener must:
  • Honor the individual’s desire to live a meaningful life.
  • Communicate in a manner that is comfortable for the individual.
  • Be sensitive regarding any trauma the individual discloses.
  • Be quality-of-life centered.
  • Listen and ensure that the individual has an active role in the LTSS screening process.
  • Collaborate with the individual regarding his or her health care choices and decisions.

 

  • Provide the individual with LTSS choices and document the individual’s choice on the DMAS-97, Individual Choice, Institutional Care or Waiver Services form.  Note that the option of HCBS program alternatives (CCC Plus Waiver or PACE) has been explained.  The LTSS Screener must have this document signed by the individual or the individual’s authorized representative and retain it in the individual’s record.

 

  • Community service options must be considered first.  Consider NF placement only when services in the community are either not a feasible alternative or the individual or the individual’s authorized representative declines HCBS.

 

  • The LTSS Screening team shall notify all individuals or individual’s authorized representative in writing of the LTSS Screening determination as well as provide a copy of the LTSS Screening packet

 

  • For each LTSS screening conducted, provide approval or denial letters.  The approval or denial letter is sent to the individual or individual’s authorized representative.  Sample approval and denial letters are located on the Medicaid Web Portal under Provider Services/Provider Forms Search at: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal

 

*[Under Category, use the drop down menu and click on Pre-Admission Screening to access the sample letters.] 

 

  • Denial letters shall include the individual’s right to appeal consistent with DMAS client appeals regulations.

 

  • Referrals for LTSS: Upon completion of the LTSS Screening, if the individual meets the NF LOC criteria for one of the Medicaid LTSS listed below, aa referral is made by the LTSS Screening Team based on the individual’s choice:

 

    • CCC Plus Waiver:

CCC Plus program member:  a copy of the completed LTSS Screening packet is provided to the health plan via the listed FAX number(s) provided later in this Chapter.

        • Should the individual need Private Duty Nursing (PDN), a copy of the LTSS Screening Packet including the DMAS-108 (adult) or DMAS-109 (child) form will also be sent to the health plan.

Fee-for-Service (FFS) member: a copy of the LTSS Screening packet is sent to the provider selected by the individual.

        • Should the individual need Private Duty Nursing (PDN), a copy of the LTSS Screening Packet including the DMAS-108 (adult) or DMAS-109 (child) form will go to appropriate DMAS staff for final authorization, please see FFS-PDN section.

 

    • PACE

A copy of the LTSS Screening packet is sent to the appropriate PACE provider.

 

    • NF services

A copy of the LTSS Screening packet is provided to the chosen nursing facility.  For CCC Plus members a copy of the completed LTSS Screening packet is also provided to the health plan via the listed FAX number(s) provided later in this Chapter.

 

Prior to the individual’s admission, the NF shall review the completed LTSS Screening packet to ensure that appropriate NF admission criteria have been met and documented (12VAC30-60-308) unless the individual meets any of the special circumstances as set out in 12VAC30-60-302.

 

  • For every LTSS screening, a copy of the DMAS-96, Medicaid LTSS Authorization Form shall be faxed to the appropriate local DSS Benefits Program (local DSS eligibility unit) where the individual resides.

 

  • LTSS Screening Teams shall not refuse a request for a LTSS Screening or bill an individual for performing a LTSS Screening required for Medicaid-funded services. This includes the responsibility of administering a LTSS Screening even if the individual is in process of appealing a former screening.  If the new LTSS Screening determines an individual meets the required level of care criteria for services, parties are responsible for notifying the DMAS appeals unit.

 

  • Individuals refusing the LTSS Screening must be informed that the LTSS Screening determines eligibility for Medicaid LTSS and if the screening is not conducted eligibility cannot be determined and Medicaid cannot be used for service payments if needed.

 

  • Individuals, families or advocates shall be instructed that only individuals admitted as an inpatient (not outpatients, patients under observational status or in the emergency department of a hospital) are required to be screened for LTSS by a hospital screener.  If outpatients or patients under observational status request a LTSS Screening, the individual should be referred to the CBT in their locality of residence for a LTSS Screening typically conducted after discharge.  Hospitals and CBTs may negotiate who will conduct the LTSS Screening in APS or other emergency situations where the individual cannot safely return home without services.

 

  • Individuals, families, or advocates shall not be required to apply for Medicaid in order to receive a LTSS Screening; and, individuals are not required to have Medicaid financial coverage determined prior to the LTSS Screening being initiated or completed.

 

  • LTSS Screening teams do not update LTSS Screening documents if an individual needs an increase in CCC Plus Waiver personal care hours. It is the responsibility of the health plan care coordinator or FFS agency/Services Facilitator provider to update the plan of care and other documents.

 

  • All LTSS screening information must be submitted and successfully processed via  eMLS.   

 

Hospital Teams – Additional LTSS Screening Requirements

 

The following information clarifies areas related to individuals admitted as an inpatient and receiving a LTSS Screening in a hospital:

 

  1. Individuals admitted to a hospital as an inpatient shall receive a LTSS Screening from the hospital when:

 

  1. The individual is eligible for Medicaid or is anticipated to become eligible for Medicaid reimbursement and may need LTSS provided through the CCC Plus Waiver, PACE or is being admitted to a NF for skilled care (including rehabilitation services) or LTSS (known as custodial or unskilled care).).; OR

b)  There is a request or referral for a LTSS Screening and regardless if the LTSS Screening entity has reason to believe that the individual is eligible or ineligible for Medicaid or is anticipated to become eligible for Medicaid reimbursement for LTSS (NF, CCC Plus Waiver, or PACE) ; and

c)  The appropriate individuals consent to the LTSS Screening.

 

If the above conditions are not met or if the individual is being treated only in the emergency department, or is under outpatient or observational status and requests a LTSS Screening or is likely to need nursing facility or hospital care within the next 30 days, the individual should be referred to the CBT for a LTSS Screening that is scheduled for completion after discharge.  If the situation is an emergency or the individual’s life is endangered upon return to a community home, or the case involves APS, LTSS teams (hospital and community) should confer as to which can most expediently conduct the LTSS Screening. 

 

  1. LTSS Screenings performed in hospitals must be completed and successfully processed in eMLS prior to hospital discharge of the individual to CCC Plus Waiver, PACE or NF. DMAS will not approve Medicaid reimbursement for an individual’s LTSS NF placement or waiver services without a successfully processed and authorized LTSS Screening prior to NF admission or the initiation of waiver services. This includes all required LTSS screening forms as reflected on thetheDMAS-P98 (inclusive of the UAI, DMAS-96, DMAS-97 and the DMAS-95 MI/ID/RC when an individual selects NF placement).

 

 

  1. .

 

Hospital teams must be aware that prior to a NF receiving Medicaid reimbursement for LTSS for an individual, a Medicaid LTSS Screening must be completed which authorizes LTSS and is successfully processed in eMLS.  

 

NFs will not be reimbursed for services until a LTSS Screening has been completed for individuals being admitted for Medicaid LTSS or who have a change in the level of care from skilled care (including rehabilitation services) to LTSS.  The individual must be  found to meet NF level of care criteria and the screening is successfully processed in    eMLS. 

 

  1. When an individual transfers from a NF to a hospital and then back to the NF, a new LTSS Screening is not needed, unless the individual has been terminated from NF services. 

 

Nursing Facility Teams – Additional LTSS Screening Requirements

The following information clarifies areas related to individuals admitted for skilled nursing facility care (including rehabilitation services) not covered by Medicaid after discharge from a hospital who may need LTSS and are screened in a NF.

 

  1. Private pay individuals admitted to a NF for skilled care (including rehab) who experience a change in the level of care potentially resulting in the need for Medicaid LTSS SHALL be screened by the NF for LTSS PRIOR to enrollment in LTSS (also known as custodial care).  The individual must be found to meet Virginia Medicaid NF level of care criteria to be enrolled and receive Medicaid paid LTSS.

 

  1. Functional capacity, medical or nursing need and risk for institutionalization shall be determined by the NF LTSS screening team via face-to-face assessment and after completion of a LTSS screening of the individual's medical/nursing, functional needs, risk status, and available supports. The NF LTSS screening team shall consider all the supports available for that individual in the community (e.g., the immediate family, other relatives, other community resources), and other services in the continuum of LTSS. The LTSS screening shall be documented on the DMAS-designated forms identified in 12VA30-60-306 and entered into the  eMLS portal.

 

  1. The individual shall be permitted to have another person present at the time of the LTSS screening. Except when a court has issued an order for a LTSS screening, the individual shall also be afforded the right to refuse to participate. The NF LTSS screening team shall determine the appropriate degree of participation and assistance given by other persons to the individual during the LTSS screening and accommodate the individual's preferences to the extent feasible.

 

Individuals refusing the LTSS Screening must be informed that the LTSS Screening determines eligibility for Medicaid LTSS and if the screening is not conducted eligibility cannot be determined and Medicaid cannot be used for service payments if needed.

 

  1. The NF LTSS screening team shall:
  1. Observe the individual's ability to perform appropriate ADLs according to 12VAC30-60-303, excluding all institutionally induced dependencies, and consider the individual's communication or responses to questions or his representative's communication or responses;
  2. Observe, assess, and report the individual's medical or nursing and functional condition.
  3. Consider services and settings that may be needed by the individual in order for the individual to safely perform ADLs.

 

  1. Upon completion of the LTSS screening and in consideration of the communication from the individual or his representative, if appropriate, and observations obtained during the LTSS screening, the NF LTSS screening team shall determine whether the individual meets the criteria set out in 12VAC30-60-303. If the individual meets the criteria for Medicaid-funded LTSS, the NF LTSS screening team shall inform the individual or his representative, if appropriate, of this determination in writing and provide choice of the setting (community or NF) and provider of LTSS.  Community options such as PACE or home and community-based waiver services (CCC Plus Waiver) shall be discussed prior to placement in NF LTSS.

 

  1. If CCC Plus Waiver services or PACE, where available, are declined, the reason for declining shall be recorded on the DMAS-97, Individual Choice - Institutional Care or Waiver Services Form. The NF LTSS screening team shall have this document signed by either the individual or his representative, if appropriate. In addition to the electronic document, a paper copy of the DMAS-97 form with the individual's or his representative's signature shall be retained in the individual's record.

 

  1. If the individual meets criteria and selects home and community-based services, the NF LTSS screening team shall also document that the individual is at risk of NF placement in the absence of home and community-based services by finding that at least one of the following conditions exists:
  1. Prior to the admission to the hospital, the individual was cared for in the home and evidence is available demonstrating a deterioration in the individual's health care condition, a significant change in condition, or a change in available supports. Examples of such evidence may include (i) recent hospitalizations, (ii) attending physician documentation, or (iii) reported findings from medical or social service agencies.
  2. There has been no significant change in condition or available support but evidence is available that demonstrates the individual's functional, medical, or nursing needs are not being met. Examples of such evidence may include (i) recent hospitalizations, (ii) attending physician documentation, or (iii) reported findings from medical or social services agencies.
  3. If the individual selects NF placement, the NF LTSS screening team shall assure that the individual is referred for Level II evaluation and determination (PASRR process) as outlined in 12VAC30-130-160 through 12VAC30-130-260 as needed and appropriate and that resident reviews of the individuals condition occur periodically.

 

  1. All individuals SHALL have a PASRR Level I Screening and if needed, Level II Evaluation and Determination PRIOR to an NF admission to a Medicaid-certified facility.  NF Screeners will need to obtain a copy of the Level I Screening, and if applicable Level II results, and transcribe that information onto the DMAS-95, DMAS-95 supplement, and Medicaid LTSS Authorization form (DMAS-96) as appropriate.

 

  1. If the NF LTSS screening team determines that the individual does not meet the criteria set out in 12VAC30-60-303, the NF LTSS screening team shall notify the individual or the individual's representative, as may be appropriate, in writing that LTSS are being denied for the individual. The denial notice shall include the individual's right to appeal consistent with DMAS client appeals regulations (12VAC30-110).

 

The following chart is provided to clarify roles and responsibilities for Medicaid LTSS Screenings related to NF admissions.

 

The following chart summarizes LTSS Screening responsibilities.

SCREENING RESPONSIBILITIES CHART FOR NFs

Funding Source

Is a LTSS Screening Required?

When is the LTSS screening completed?

Who completes the Medicaid LTSS Screening?

Private Pay*

NO

Not Applicable (NA)

NA

Medicare Only*

NO

NA

NA

Dual Medicare & Medicaid

YES

Prior to admission to SNF or ICF (LTSS)

Hospital (if inpatient)

Community-based Team (community resident)**

Medicaid (partial or full) or Medicaid  pending (having applied for Medicaid or planning on applying for Medicaid)

YES

Prior to admission to SNF or ICF (LTSS)

Hospital (if inpatient)

Community-based Team (community resident)

Private Pay or Medicare applying for Medicaid while in SNF

YES

Change of Level of Care from SNF to LTSS

Nursing Facility

REQUESTS: Any time a person requests a LTSS Screening one shall be conducted, regardless of payment source.

 

YES

When requested

Community-based Team, Hospital or Nursing Facility

 

 

 

 

Use of the MDS and Physician’s Signature Certifying NF LOC

Special Circumstances with  Direct Admissions to SNF or LTSS NF

(i.e. from veterans’ facility, DBHDS facility, or out-of-state)

 

NO LTSS Screening

MDS and Physician signature certifies NF LOC

Handled by NF

Private Pay individual becomes financially eligible for Medicaid while in NF LTSS

 

NO LTSS Screening

MDS and Physician signature certifies NF LOC

Handled by NF

 

*    

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For the purposes of this chart, Private Pay refers to ANY payment source other than Medicaid or partial Medicaid payment.

**    Community-Based Teams are continuing to conduct ALL screenings as requested and referred.

*** ALL individuals, regardless of payment source, who are being considered for admission to a Medicaid-certified NF (SNF or LTSS NF) SHALL be screened for mental illness, intellectual disability or related conditions, PRIOR to NF admission.  This is referred to as the PreAdmission and Resident Review (PASRR) process.  Community-Based Teams – Additional LTSS Screening Requirements

 

The following information clarifies issues related to individuals Screened by the CBTs.

 

CBTs are responsible for all requests and referrals for individuals residing within the jurisdiction of the CBT (who are not inpatients in a hospital) unless there is a special circumstance as previously outlined. 

 

For adults, a CBT shall consist of both a public health nurse from the local health department, and a social worker or a family services specialist from the local department of social services.

 

For children, the local health department is considered the DMAS community designee for LTSS Screenings.  A CBT shall consist of the public health nurse from the local health department, and may include a social worker or a family services specialist from the local department of social services. For children, it is the locality that decides the final members of the CBT. 

 

For both adult and child community LTSS Screenings, a physician (or the nurse practitioner or physician’s assistant working with the physician) working in the local health district must review the screening information, confirm the LTSS Screening determination and sign the Medicaid LTSS Authorization form.

 

For the LTSS Screening to be scheduled by the CBT, the individual or his representative must agree to participate and consent to allow the CBT to collect and share information necessary for the completion of the LTSS Screening.  If an individual refuses to participate in the LTSS Screening, the LTSS Screening shall proceed only under order of a court in the appropriate jurisdiction.  Individuals refusing the LTSS Screening must be informed that the LTSS Screening determines eligibility for Medicaid LTSS and if the screening is not conducted eligibility cannot be determined and Medicaid cannot be used for service payments if needed.

 

 

  1. Determine if the individual is currently enrolled for Medicaid LTSS. If the individual is currently enrolled for Medicaid LTSS and is not receiving services, the screening team may refer the individual back to the identified provider or care coordinator to assist with establishing services or addressing issues involving, specific services or number of hours for authorized services. 

 

  1. Individuals in the community shall be screened by the CBT when:
    • Individuals who are Medicaid members or likely to become eligible for Medicaid shall be screened for LTSS, OR
    • There is a request for a LTSS Screening.  All requests for a LTSS Screening must be honored.  LTSSLTSS Screenings shall be conducted regardless of whether the person has applied for Virginia Medicaid. This includes the responsibility of completing a LTSS Screening even if the individual is in process of appealing a former screening.  If the new LTSS Screening determines an individual meets the required level of care criteria for services, parties are responsible for notifying the DMAS appeals unit.
  1.   

 

 

  1. Each CBT shall contact the individual or his representative within seven (7) calendar days of the request date for a LTSS Screening to schedule the LTSS Screening with the individual. It is the responsibility of the CBT to coordinate contacts and scheduling between the LDSS and LHD using the most efficient method agreed to between the two agencies.
    • The “request date for a LTSS Screening” means “the date that an individual, an emancipated child, the individual’s representative, an Adult or Child Protective Services Worker, physician, CSB Support Coordinator, or the individual's health plan  health plan contacts the LTSS Screening entity in the jurisdiction where the individual resides asking for assistance with LTSS.”

 

  1. When the LDSS or LHD receives a referral for a LTSS Screening, the LDSS or LHD shall obtain sufficient information from the referral source to initiate contact with the individual or his representative to discuss the LTSS Screening process.
    • Within seven (7) days of the referral date for a LTSS Screening, the LDSS or LHD shall contact the individual or his representative to determine if the individual is interested in receiving LTSS and would participate in the LTSS Screening.
    • If the LDSS or LHD is unable to contact the individual or his representative, the attempts shall be documented using the method adopted by the CBT.
    • After contact with the individual (or his representative) or if the LDSS or LHD is unable to contact the individual or his representative, the LDSS or LHD shall advise the referring  person that contact or attempt to contact has been made in response to the referral for LTSS Screening.
    • With either the individual's written consent or the written consent of his legal representative information about the results of the contact (not the actual LTSS Screening or the LTSS Screening determination) may be shared with the interested person who made the referral. .

 

  1. CBTs shall complete and submit all LTSS Screenings to  eMLS as soon as possible but within 30 calendar days of the request date for the Screening to assure delivery of services to individuals seeking LTSS and to document efforts to achieve timely and appropriate LTSS Screenings.

 

  1. A LTSS Screening shall be completed in the individual's residence unless the residence presents a safety risk for the individual or the CBT, or unless the individual or the representative requests that the LTSS Screening be performed in an alternate location within the same jurisdiction (alternate location may include a hospital emergency department or someone in observation status when there is an urgent need). The CBT shall accommodate the individual's preferences to the extent feasible.

 

Residence means the location in which the individual is living, for example, an individual's private home, apartment, assisted living facility, children’s residential facility, NF or jail/correctional facility. 

 

CBTs are allowed to conduct LTSS Screenings for individuals who are residing in a NF when a copy of the original LTSS Screening cannot be documented or located and the individual chooses to leave the NF and receive HCBS.  This action would be considered conducting a LTSS Screening for a significant change in condition.

 

Note: Individuals Who Are Inmates

 

Inmates in local jails or correctional facilities who are ready for release back into the community may require a LTSS Screening if they need HCBS (CCC Plus Waiver or PACE) NF services or  NF services.  The CBT in the jurisdiction where the correctional facility is located is responsible for conducting the LTSS Screening.

 

  1. In order to be consistent with 42CFR § 441.302 which states that individuals are to be reevaluated at least annually, enrollment in home and community-based services (CCC Plus Waiver and PACE) must occur within one year of the date of authorization for LTSS.  If an enrollment has not occurred within one year of the LTSS Screening, a new LTSS Screening shall be conducted to document the level of care and assure need for services.

 

 

  1. VDH and DARS are the state agencies responsible for the oversight of the LHD and LDSS LTSS Screening activities, respectively. Both VDH and DARS have staff identified to provide technical assistance to the CBT upon notification that a LTSS Screening has not been scheduled within 21 days of the request date for a LTSS Screening or when the CBT anticipates that a LTSS Screening will not be completed within 30 days of the request date for a LTSS Screening.

 

For Technical Assistance for the LHD:

PAS Program Manager

Department of Health

109 Governor Street

Richmond, VA 23219

 

Grace.Hughes@vdh.virginia.gov

 

For Technical Assistance for LDSS Adult Services/ Screeners:

Auxiliary Grant Program Manager

Adult Protective Services Division

Department for Aging and Rehabilitative Services (DARS)

8004 Franklin Farms Drive

Richmond, VA 23229

Phone: 804-662-7531

Tishaun.HarrisUgworji@dars.virginia.gov   

Federal Preadmission Screening and Review (PASRR) Process

The following process applies to all Medicaid-certified nursing facility admissions regardless of payer source or reason for admission.

Level I Screening and Level II Evaluation and Determination for Individuals Entering Nursing Facilities

 

Mental Illness (MI), Intellectual Disability (ID), and/or Related Condition (RC) Evaluations and Determinations

Federal law requires that ALLALL individuals (regardless of payer source) who apply as a new admission to a Medicaid-certified NF be evaluated for evidence of possible MI, ID, or RC. This evaluation and determination is conducted to ensure that individuals are placed appropriately, in the least restrictive setting possible and that individuals receive needed services, wherever they are livingThe process involves two steps, known as Level I screening and Level II  and determination.  The use of a Level I screening and Level II evaluation and determination is federally known as the Preadmission Screening and Resident Review (PASRR) process. By federal law, an individual shall not be admitted to a NF unless a Level I screening has been completed, and, if it is determined that the individual may have a condition of MI/ID or RC, then the individual shall not be admitted until the Level II evaluation and determination has been completed.

 

The Omnibus Budget Reconciliation Act (OBRA) of 1987, Part 2, Subtitle C of Title IV, added §1919 to the Social Security Act prohibits Medicaid-certified NFs from admitting ANY new resident who may have MI, ID, or a RC unless that individual has been determined by the State Mental Health Authority (MHA) or State Intellectual Disability Agency (IDA) to require the level of services provided by a NF and/or the individual receives Specialized Services if needed. 

 

The PASRR Level I Screening and Level II evaluation and determination (DMAS-95 MI/ID/RC Form) are not completed for individuals choosing the CCC Plus Waiver or PACE.   

 

Medicaid-certified NFs must have a policy on file describing how the MI/ID/RC screening (Level I) and referral for evaluation and determination (Level II), when needed, will be handled for non-Medicaid-eligible individuals, or when the information is not part of the Medicaid LTSS Screening packet.  This means each NF should have a written policy for how private pay, Medicare, persons admitted under special circumstances and those transferred from CCC Plus Waiver or PACE to NF, receive Level I Screening and, as needed, Level II evaluations and determinations.  NFs may use the Level I form developed by DMAS, entitled, Level I Screening for Mental Illness, Intellectual Disability and Related Conditions, found at http://www.dmas.virginia.gov/#/longtermprograms

 

A PASRR Level I screening must be completed for all persons applying for admission  to a Medicaid-certified nursing facility for all short-term and long-term services. This includes private pay, skilled or rehabilitation admissions regardless of payer source.   NFs shall have procedures in place to ensure Level I screenings are conducted which could include use of qualified NF staff for Level I screenings, and, when needed, assure  Level II evaluations are sent to the designated Level II contractor.  Any individual who is seeking admission to a NF and has not been screened for Medicaid LTSS must receive a Level I screening following the NFs procedures and when a Level II evaluation and determination is needed the NF will ensure that necessary documentation and information is submitted to the designated Level II contractor.

 

 

PASRR Level I Screening

 

When it is determined that an individual chooses or requires NF services, a DMAS-95 MI/ID/RC or MI/ID/RC Level I Screening form is completed by the Medicaid LTSS Screener or party responsible for the PASRR process.  A Level I screening, and a Level II evaluation and determination, if indicated, must be completed before a resident can be admitted into a nursing facility. When it is unsuspected or unknown that an individual has MI, ID, or RC findings must be documented on the Level I Screening form or DMAS-95. If the individual requires a Level II evaluation and determination, the responsible party forwards the completed Level I Screening form or DMAS-95to the DBHDS contractor (contact information follows) for further evaluation.

PASRR Level II Evaluation and Determination

 

Level II is an in-depth evaluation.  Virginia’s Level II process includes the participation of a representative from the DBHDS and the contractor performing the reviews. 

 

The Level II evaluation determines if the individual may benefit from additional specialized services and does not preclude an individual from receiving NF services. The  following documents SHALL be provided to the Level II contractor:

 

  • Completed UAI or equivalent assessment of ability to complete ADLs and IADLs,

Level I Screening form or DMAS-95 and Guardianship documentation (if applicable).

  • Medical History and physical, signed by a physician and performed within 1 year of the screening date.
  • Psychiatric Evaluation for individuals already diagnosed with severe mental illness (SMI), signed by a psychiatrist and performed within one (1) year of the screening date.
  • Intelligence testing for ID. - If not available the Level II evaluator will perform this test if an ID or RC is suspected.

 

DBHDS and contractor completes the Level II evaluation and determination prior to NF admission. The Level II results must be returned to the responsible party and if it a Medicaid LTSS Screener, the Level II Screening and determination is to be entered  into the  eMLS

 

NFs cannot admit an individual without a Level I screening and, if needed, a Level II evaluation and determination. The results from DBHDS and the contractor are documented on the DMAS-96 Authorization Form. The Level II evaluation and determination must be made in writing within an annual average of 7 to 9 working days of referral of the individual with MI/ID or RC by whatever agent performs the Level I identification.  The DBHDS contractor contact information is:

 

Ascend, A Maximus Company

Phone: 877-431-1388, Extension 3205

Fax: 877-431-9568

Website: www.ascendami.com

Screening for Medicaid-Funded LTSS Level of Care (LOC) Authorization Criteria (PAS)

Attachment B of this chapter provides a worksheet to assist in determining if an individual meets NF LOC criteria.  Results from the Screening can be entered on the two-page worksheet (Attachment B) that assists with summarizing the information gathered and considers the NF LOC criteria.

Adult Screening Criteria for Medicaid-Funded LTSS (PAS)

The LTSS Screening criteria for assessing an adult’s eligibility for Medicaid reimbursement of LTSS consists of several components as follows:

 

    1. Functional capacity: evaluates an individual's ability to independently perform activities of daily living (ADLs),demonstrate mobility, joint motion, and medication administration and assess behavior and orientation status as measured on the UAI. This capacity assessment should be conducted face-to-face and to the extent possible observed by the Screener. The assessment considers how an individual functions in a community environment and excludes all institutionally induced dependencies.  IADLs may also be assessed to assist in determining needs for community (non-Medicaid) resources.

 

    1. Medical or nursing needs: determines if the individual meets the medical or nursing need criteria for NF level of care.

 

    1. In order to qualify and be authorized for Medicaid reimbursement for LTSS, an individual must also be at risk for NF placement within 30 days in the absence of the CCC Plus Waiver or PACE (42CFR441.302(c)(1)).  “At Risk” also includes the need for the level of care provided in a hospital.

 

Individuals may be screened for the CCC Plus Waiver or PACE while they are on the waiting list for the Building Independence (BI); Family & Individual Services (FIS); or Community Living (CL) Waivers.  However, the individual must meet the criteria for the services for which they seek enrollment in order to be authorized.  Please note that eligibility for CCC Plus Waiver, PACE or NF services does not indicate eligibility for one of the Developmental Disability (DD) Waivers nor is someone who is a participant in a DD waiver automatically eligible for CCC Plus Waiver, PACE or NF services.

 

It should be noted that the authorization for Medicaid-funded LTSS may be rescinded by the LTSS provider (including CCC Plus health plan or PACE) at any point in time that the individual is determined to no longer meet the criteria for Medicaid-funded LTSS. 

 

Functional Capacity

Functional capacity is the degree of independence that an individual can perform ADLs, demonstrate mobility, joint motion, and medication administration, and the individual’s behavior and orientation status as measured on the UAIUAI.  These can be measured and are commonly used as a basis for differentiating levels of long-term services and supports.  This capacity assessment should be conducted face-to-face and to the extent possible observed by the Screener.

 

An individual may meet the functional capacity requirements for NF care when one of the following applies:

 

1.           Rated dependent in two or more ADLs, and also rated semi-dependent or  dependent in Behavior Pattern and Orientation, and semi-dependent or dependent in Joint Motion or dependent in Medication Administration; or

 

2.           Rated dependent in five to seven ADLs and also rated dependent in Mobility; or

 

3.           Rated semi-dependent or dependent in two or more of the ADLs and also rated dependent in Mobility and Behavior Pattern and Orientation.

 

 

The following abbreviations are used on the UAI and mean:

 

I = independent

d= semi-dependent

D= dependent

 

Activities of Daily Living (ADLs)

Bathing,, Dressing,, Toileting, Transferring

Rating

Without help

I

Mechanical Help (MH) only

d

Human Help only (HH)

D

MH & HH

D

Performed by others

D

Is not performed

D

Bowel Function

 

Continent

I

 

Incontinent less than weekly

d

 

External/In-dwelling device/Ostomy self-care

d

 

Incontinent weekly or more

D

 

Ostomy - not self-care

D

 

Bladder Function

 

Continent

I

 

Incontinent less than weekly

d

 

External/In-dwelling device/ Ostomy-self-care

d

 

Incontinent weekly or more

D

 

External device - not self-care

D

 

Indwelling catheter - not self-care

D

 

Ostomy - not self-care

D

 

Eating/Feeding

 

Without help

I

 

Mechanical help (MH) only

d

 

Human help only (HH)

D

 

MH & HH

D

 

Spoon Fed

D

 

Syringe or Tube Fed

D

 

Tube fed by IV or clysis

D

 

 

 

 

Joint Functioning

 

 

Within normal limits or instability corrected

I

 

Limited motion

d

 

Instability - uncorrected or immobile

D

 

Mobility

 

 

Goes outside without help

I

 

Goes outside with Mechanical help (MH) only

d

 

Goes outside with Human help only (HH)

D

 

Goes outside with MH & HH

D

 

Confined - moves about

D

 

Confined – does not move about

D

 

Medication Administration

 

 

No medications

I

 

Self-administered – monitored less than weekly

I

 

By lay persons administered/monitored

D

 

By licensed/ professional nurse administered/ monitored

D

 

Orientation

 

 

Oriented

I

 

Disoriented – Some spheres, some of the time

d

 

Disoriented – Some spheres, all the time

d

 

Disoriented – All spheres, some of the time

D

 

Disoriented – All spheres, all of the time

D

 

Comatose

D

 

Behavior

 

 

Appropriate

I

 

Wandering/Passive-Less than Weekly

I

 

Wandering/Passive - Weekly or More

d

 

Abusive/Aggressive/Disruptive - Less than Weekly

D

 

Abusive/Aggressive/Disruptive - Weekly or More

D

 

Comatose

D

 

       

 

Medical or Nursing Needs

 

An individual with medical or nursing needs is an individual whose health needs require medical or nursing supervision or care above the level, which could be provided through assistance with ADLs, medication administration, and general supervision and is not primarily for the care and treatment of mental diseases (12VAC30-60-303. D.). 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 ensure evaluation of the individual’s need for modification of treatment or additional medical procedures to prevent destabilization, and the individual has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals; or

 

  1. Due to the complexity created by the individual’s multiple, inter-related medical conditions, the potential for the individual’s medical instability is high or medical instability exists; or

 

  1. The individual requires at least one ongoing medical or nursing service.  Ongoing means that the medical/nursing needs are continuing, not temporary, or where the individual is expected to undergo or develop changes with increasing severity in status.  “Ongoing” refers to the need for daily direct care and/or supervision by a licensed nurse that cannot be managed on an outpatient basis. 

 

If applicable, specify the ongoing medical/nursing need in  eMLS.  An individual who is receiving rehabilitation services and/or special medical procedures does not automatically have ongoing medical or nursing needs as there should be documentation to support the rehabilitation services and/or ongoing special medical procedures such as physician orders or progress notes.

 

Note: NF LOC for an individual is not determined by an individual’s age, nor a specific diagnosis or therapy.

 

The following is a non-exclusive list of medical or nursing services that MAY indicate a need for medical or nursing supervision or care:

 

  1. Application of aseptic dressings;

 

  1. Routine catheter care;

 

  1. Respiratory therapy;

 

  1. Supervision for adequate nutrition and hydration for individuals who show clinical evidence of malnourishment or dehydration or have a recent history of weight loss or inadequate hydration which, if not supervised, would be expected to result in malnourishment or dehydration (this also includes observation and supervision of special diets, e.g. diabetic, renal, cardiac, etc.);

 

  1. Therapeutic exercise and positioning;

 

  1. Routine care of colostomy or ileostomy or management of neurogenic bowel and bladder;

 

  1. Use of physical (e.g., side rails, Posey vests, geri-chairs, locked units) or chemical restraints (e.g. overuse of sedatives), or both;

 

  1. Routine skin care to prevent pressure ulcers for individuals who are immobile or whose medical condition increased the risk of skin breakdown;

 

  1. Care of small uncomplicated pressure ulcers and local skin rashes;

 

  1. Management of those with sensory, metabolic, or circulatory impairment with demonstrated clinical evidence of medical instability;

 

  1. Chemotherapy;

 

  1. Radiation;

 

  1.  Dialysis including observation of and care of the access port;

 

  1. Suctioning;

 

  • Tracheostomy care;

 

  1. Infusion therapy;

 

  1. Oxygen;

 

Examples of Medical or Nursing Needs:

 

  • Drainage Tubes

 

  • End-Stage Disease

 

  • Naso-gastric Tube Feeding

 

  • Total Parenteral Nutrition management and care as directed

 

  • Severe Daily Pain Management as directed by physician

 

  • Transplant management and care as directed

 

  • Uncontrolled Seizures management and observation

 

  • Use of Ventilator

 

A medical situation that requires complex medical care or equipment to sustain life may be a reason for an individual to need PDN services.  In these circumstances the individual may not meet functional criteria but would be considered in need of NF LOC.  The DMAS-108 (for adults) or a DMAS-109 (for children) is completed for these cases.

 

PDN exception note: If the individual is rated dependent in some functional limitations, but does not meet the functional capacity requirements, it should be determined if the individual requires the daily direct services or supervision of a licensed nurse for PDN services that cannot be managed on an outpatient basis (e.g. clinic, physician visits, home health services).

 

Rating Criteria for Adult Assessments

 

It is mandatory, when assessing an adult, to use the rating criteria below that indicates the individual’s functional capacity and medical need.  When reviewing for dependencies, LTSS Screening teams should rate at the individual’s highest level of need,  which allows the person to perform the activity safely, reliably and completely from beginning to end.

 

 

Rating Criteria for Bathing:

  

Bathing entails getting in and out of the tub, preparing the bath (e.g., turning on the water), actually washing oneself, and towel drying. Some individuals may report various methods of bathing that constitute their usual pattern. For example, they may bathe themselves at a sink or basin five days a week, but take a tub bath two days of the week when an aide assists them. The questions refer to the method used most or all of the time to bathe the entire body.

 

  • Does Not Need Help (I):  Individual gets in and out of the tub or shower, turns on the water, bathes entire body, or takes a full sponge bath at the sink and does not require immersion bathing, without using equipment or the assistance of any other person.

 

  • Mechanical Help Only (d):  Individual usually needs equipment or a device such as a shower/tub chair/stool, grab bars, pedal/knee-controlled faucet, long-handled brush, and/or a mechanical lift to complete the bathing process.

 

  • Human Help Only (D): 

 

Supervision (Verbal Cues, Prompting):  Individual needs prompting and/or verbal cues to safely complete washing the entire body. This includes individuals who need someone to teach them how to bathe. 

 

Physical Assistance (Set-up, Hands-On Care):  Someone fills the tub or brings water to the individual, washes part of the body, helps the individual get in and out of the tub or shower, and/or helps the individual towel dry. Individuals who only need human help to wash their backs or feet would not be included in this category.  Such individuals would be rated as "Does Not Need Help".

 

  • Mechanical and Human Help (D):  Individual usually needs equipment or a device and requires assistance of other(s) to bathe.

 

  • Performed by Others (D):  Individual is completely bathed by other(s) and does not take part in the activity at all.

 

 

 

Rating Criteria for Dressing:

 

Dressing is the process of getting clothes from closets and/or drawers, putting them on, fastening, and taking them off. Clothing refers to clothes, braces and artificial limbs worn daily.  Individuals who wear pajamas or gown with robe and slippers as their usual attire are considered dressed. 

 

  • Does Not Need Help (I):   Individual usually completes the dressing process without help from others. If the only help someone gets is tying shoes, do not count as needing help.

 

  • Mechanical Help Only (d):  Individual usually needs equipment or a device such as a long-handled shoehorn, zipper pulls, specially designed clothing or a walker with an attached basket to complete the dressing process.

 

  • Human Help Only (D): 

 

Supervision (Verbal Cues, Prompting):  Individual usually requires prompting and/or verbal cues to complete the dressing process. This category also includes individuals who are being taught to dress. 

 

Physical Assistance (Set-up, Hands-On Care): Individual usually requires assistance from another person who helps in obtaining clothing, fastening hooks, putting on clothes or artificial limbs, etc.

 

  • Mechanical and Human Help (D):   Individual usually needs equipment or a device and requires assistance of other(s) to dress.

 

  • Performed by Others (D):  Individual is completely dressed by another individual and does not take part in the activity at all.

 

  • Is Not Performed (D):  Refers only to individuals confined to bed who are considered not dressed.

 

Rating Criteria for Toileting:

 

Toileting is the ability to get to and from the bathroom, get on/off the toilet, clean oneself, manage clothes and flush. A commode at any site may be considered the "bathroom" only if in addition to meeting the criteria for "toileting" the individual empties, cleanses, and replaces the receptacle, such as the bed pan, urinal or commode, without assistance from other(s).

 

  • Does Not Need Help (I):  Individual uses the bathroom, cleans self, and arranges clothes without help.  This includes appropriate use and disposal of incontinent supplies or pads by the individual.

 

  • Mechanical Help Only (d):  Individual needs grab bars, raised toilet seat or transfer board and manages these devices without the aid of other(s).  Includes individuals who use handrails, walkers, wheelchairs, or canes for support to complete the toileting process. Also includes individuals who use the bathroom without help during the day, use a bedpan, urinal, or bedside commode without help during the night, and can empty this receptacle without assistance. This category includes appropriate use and disposal of incontinent supplies or pads by the individual.

 

  • Human Help Only (D):

 

Supervision (Verbal Cues, Prompting):  Individual requires verbal cues and/or prompting to complete the toileting process. 

 

Physical Assistance (Set-up, Hands-On Care):  Individual usually requires assistance from another person who helps in getting to/from the bathroom, adjusting clothes, transferring on and off the toilet, or cleansing after elimination. The individual participates in the activity. This includes supervision and/or physical assistance with incontinent supplies or pads.

 

  • Mechanical and Human Help (D):   Individual usually needs equipment or a device and requires assistance of other(s) to toilet.

 

  • Performed by Others (D):   Individual does use the bathroom, but is totally dependent on another's assistance. Individual does not participate in the activity at all. This includes total assistance by others with incontinent supplies or pads.

 

  • Is Not Performed (D):  Individual does not use the bathroom. 

 

Rating Criteria for Transferring:

 

Transferring means the individual’s ability to move between the bed, chair, and/or wheelchair. If a person needs help with some transfers but not all, rate assistance at the highest level.

 

  • Does Not Need Help (I):   Individual usually completes the transferring process without human assistance or use of equipment.

 

  • Mechanical Help Only (d):  Individual usually needs equipment or a device, such as lifts, hospital beds, sliding boards, pulleys, trapezes, railings, walkers or the arm of a chair, to safely transfer, and individual manages these devices without the aid of another person.

 

  • Human Help Only (D):

 

Supervision (Verbal Cues, Prompting):  Individual usually needs verbal cues or guarding to safely transfer. 

 

Physical Assistance (Set-up, Hands-On Care):  Individual usually requires the assistance of another person who lifts some of the individual's body weight and provides physical support in order for the individual to safely transfer.

 

  • Mechanical and Human Help (D):  Individual usually needs equipment or a device and requires the assistance of other(s) to transfer.

 

  • Performed By Others (D):  Individual is usually lifted out of the bed and/or chair by another person and does not participate in the process. If the individual does not bear weight on any body part in the transferring process; he/she is not participating in the transfer. Individuals who are transferred with a mechanical or Hoyer lift are included in this category.

 

  • Is Not Performed (D):  The individual is confined to the bed.

 

 

Rating Criteria for Eating/Feeding:

 

Eating/Feeding is the process of getting food/fluid by any means into the body. This activity includes cutting food, transferring food from a plate or bowl into the individual's mouth, opening a carton and pouring liquids, and holding a glass to drink. This activity is the process of eating food after it is placed in front of the individual.

 

  • Does Not Need Help (I):   Individual is able to perform all of the activities without using equipment or the supervision or assistance of another.

 

  • Mechanical Help Only (d):  Individual usually needs equipment or a device, such as hand splints, adapted utensils, and/or nonskid plates, in order to complete the eating process. Individuals needing mechanically adjusted diets (pureed food) and/or food chopped are included in this category. 

 

  • Human Help Only (D): 

 

Supervision (Verbal Cues, Prompting):  Individual feeds self, but needs verbal cues and/or prompting to initiate and/or complete the eating process. 

 

Physical Assistance (Set-up, Hands-On Care):  Individual needs assistance to bring food to the mouth, cut meat, butter bread, open cartons and/or pour liquid due to an actual physical or mental disability (e.g., severe arthritis, Alzheimer's). This category must not be checked if the individual is able to feed himself but it is more convenient for the caregiver to complete the activity.

 

  • Mechanical and Human Help (D):  Individual usually needs equipment or a device and requires assistance of other(s) to eat.

 

  • Performed By Others (D):   Includes individuals who are spoon fed; fed by syringe or tube, or individuals who are fed intravenously (IV). Spoon fed means the individual does not bring any food to his mouth and is fed completely by others. Fed by syringe or tube means the individual usually is fed a prescribed liquid diet via a feeding syringe, NG-tube (tube from the nose to the stomach) or G-tube (opening into the stomach). Fed by I.V. means the individual usually is fed a prescribed sterile solution intravenously. Total parenteral nutrition (TPN) is the administration of a nutritionally adequate solution through an indwelling catheter into the superior vena cava.

 

Rating Criteria for Bowel:

 

Bowel continence is the physiological process of elimination of feces.

 

Continence is the ability to control bowel elimination. Incontinence may have one of several different causes, including specific disease processes and side effects of medications. Helpful questions include, Do you get to the bathroom on time?; "How often do you have accidents?”, and "Do you use pads or adult diapers?"

 

  • Does Not Need Help (I):  This category includes: 1) the individual voluntarily controls the elimination of feces. OR 2) If the individual on a bowel program never empties his or her bowel without stimulation or a specified bowel regimen, he or she is rated as “Does not need help,” and the bowel/bladder training is noted under medical/nursing needs because in this case, there is no voluntary elimination; evacuation is planned. If an individual on a bowel regimen also has occasions of bowel incontinence, then he or she would be rated as incontinent, either less than weekly or weekly or more. OR 3) If an individual uses incontinent supplies such as briefs, pads or diapers and can independently change and dispose of items appropriately, then the individual is rated “Does not need help.”

 

  • Incontinent Less than Weekly [does not occur every week] (d):  The individual has involuntary elimination of feces but it does not occur every week (e.g., every other week). Includes individuals who use incontinence supplies such as briefs, pads, or diapers for involuntary elimination of feces and the individual is unable to properly dispose of the items but it does not occur every week.  In these cases, the individual is rated as “incontinent less than weekly.”

 

  • Ostomy - Self-Care (d):   The individual has an artificial anus established by an opening into the colon (colostomy) or ileum (ileostomy) and can independently care for the ostomy, stoma, skin cleansing, dressing, application of appliance, irrigation, etc., and if needed with ostomy, can appropriately change and dispose of incontinence supplies used.

 

  • Incontinent Weekly or More [Occurring at least once a week or more] (D):  The individual has involuntary elimination of feces at least once a week or more. Includes individuals who use incontinence supplies such as briefs, pads, or diapers for involuntary elimination of feces occurring at least once a week or more and does not correctly dispose of incontinence supplies.

 

  • Ostomy - Not Self-Care (D):  The individual has an artificial anus established by an opening into the colon (colostomy) or ileum (ileostomy) and another person cares for the ostomy, stoma, skin cleansing, dressing, application of appliance, irrigations, etc., and may also need assistance with the changing and appropriate disposal of incontinence supplies.

 

Rating Criteria for Bladder:

 

Bladder continence is the physiological process of elimination of urine.

 

Continence is the ability to control urination (bladder). Incontinence may have one of several different causes, including specific disease processes and side effects of medications. Helpful questions include, "Do you get to the bathroom on time?"; "How often do you have accidents?, and "Do you use pads or adult diapers?"

 

  • Does Not Need Help (I):  This category includes:

1) The individual voluntarily empties his or her bladder. OR

2) Individuals on dialysis who have no urine output would be rated “Does not need help” as he or she does not perform this process. Dialysis will be noted under medical/nursing needs. OR

3) Similarly, individuals who perform the Crede method for himself or herself for bladder elimination would also be rated “Does not need help.” OR

4) If an individual uses incontinent supplies such as briefs, pads or diapers and can independently change and dispose of them appropriately, then the individual is rated “Does not need help”.

 

  • Incontinent Less than Weekly [does not occur every week] (d):   The individual has involuntary emptying or loss of urine but it does not occur every week.  Includes individuals who use incontinence supplies such as briefs, pads, or diapers for involuntary emptying or loss of urine and the individual is unable to properly dispose of the items but it does not occur every week.  In these cases, the individual is rated as “incontinent less than weekly.”

 

  • External Device, Indwelling Catheter, or Ostomy - Self Care (d):   The individual has an urosheath or condom with a receptacle attached to collect urine (external catheter); a hollow cylinder passed through the urethra into the bladder (internal catheter);  a surgical procedure that establishes an external opening into the ureter(s) (ostomy)or may include in and out catheterizations occurring multiple times a day (not indwelling). The individual completely cares for urinary devices (changes the catheter or external device, irrigates as needed, empties and replaces the receptacle) and the skin surrounding the ostomy This includes individuals who use any of these devices and may also need to use incontinence supplies such as briefs, pads, or diapers but can correctly dispose of them.

 

  • Incontinent Weekly or More [Occurring at least once a week or more] (D):   The individual has involuntary emptying or loss of urine at least once a week or more. Includes individuals who use incontinence supplies such as briefs, pads, or diapers for involuntary emptying or loss of urine occurring at least once a week or more and does not correctly dispose of them.

 

  • External Device - Not Self-Care (D):  Individual has an urosheath or condom with a receptacle attached to collect urine. Another person cares for the individual's external device. This includes individuals who use these devices and may need to use incontinence supplies such as briefs, pads, or diapers but cannot correctly dispose of them.

 

  • Indwelling Catheter - Not Self-Care (D):  Individual has a hollow cylinder passed through the urethra into the bladder. Another person cares for the individual's indwelling catheter or must perform in and out catheterizations multiple times a day. This category includes individuals who self-catheterize, but who need assistance to set-up, clean up, etc. This includes individuals who use these devices and may need to use incontinence supplies such as briefs, pads, or diapers but cannot correctly dispose of them.

 

  • Ostomy - Not Self-Care (D):  Individual has a surgical procedure that establishes an external opening into the ureter(s). Another person cares for the individual's ostomy and may assist with the use, changing, and appropriate disposal of incontinence supplies. 

 

 

Rating Criteria for Mobility:

 

Mobility is the extent of the individual's movement outside his or her usual living quarters. Evaluate the individual's ability to walk steadily and his or her level of endurance.

 

Ambulation is the ability to get around indoors (walking) and outdoors (mobility), climb stairs and wheel. Individuals who are confined to a bed or chair must be shown as needing help for all ambulation activities. This is necessary in order to show their level of functioning/dependence in ambulation accurately. Individuals who are confined to a bed or a chair are rated Is Not Performed for all ambulation activities.

 

Walking is the process of moving about indoors on foot or on artificial limbs.

 

Wheeling is the process of moving about by a wheelchair. The wheelchair itself is not considered a mechanical device for this assessment section.

 

Stair Climbing is the process of climbing up and down a flight of stairs from one floor to another. If the individual does not live in a dwelling unit with stairs, ask whether he can climb stairs if necessary.

 

  • Does Not Need Help (I):  Individual usually goes outside of his or her residence on a routine basis. If the only time the individual goes outside is for trips to medical appointments or treatments by ambulance, car, or van, do not rate the individual here because this is not considered going outside. These individuals would be rated either in the "confined - moves about" or "confined - does not move about" categories.

 

  • Mechanical Help Only (d):  Individual usually needs equipment or a device to go outside. Equipment or device includes splint, special shoes, leg braces, crutches, walkers, wheelchairs, canes, handrails, chairlifts, and special ramps. 

 

  • Human Help Only (D): 

 

Supervision (Verbal Cues, Prompting):  Individual usually requires assistance from another person who provides supervision, cues, or coaxing to go outside. 

 

Physical Assistance (Set-up, Hands-On Care):  Individual usually receives assistance from another person who physically supports or steadies the individual to go outside.

 

  • Mechanical and Human Help (D):  Individual usually needs equipment or a device and requires assistance of other(s) to go outside.

 

  • Confined - Moves About (D):  Individual does not customarily go outside of his or her residence, but does go outside of his or her room.

 

  • Confined - Does Not Move About (D):  The individual usually stays in his or her room. 

 

Rating Criteria for Joint Motion:

 

This is the individual’s ability to move his or her fingers, arms, and legs (active range of movement or ROM) or, if applicable, the ability of someone else to move the individual’s fingers, arms, and legs (passive ROM). 

 

  • Within normal limits or instability corrected (I):  means the joints can be moved to functional motion without restriction, or a joint does not maintain functional motion and/or position when pressure or stress is applied, but has been corrected by the use of an appliance or by surgical procedure. 

 

  • Limited motion (d):  means partial restriction in the movement of a joint including any inflammatory process in the joint causing redness, pain, and/or swelling that limits the motion of the joint.

 

  • Instability uncorrected or immobile (D):  means a joint does not maintain functional motion and/or position when pressure or stress is applied and the disorder has not been surgically corrected or an appliance is not used, or there is total restriction in the movement of a joint (e.g., contractures, which are common in individuals who have had strokes).

 

Rating Criteria for Medication Administration:

 

Medication Administration refers to the person(s) who administer medications or if the individual is being referred elsewhere, the person(s) who will administer medications following referral. 

 

  • Without Assistance or No Medications (I):  No Medications means the individual takes medication without any assistance from another person or is monitored by another individual less than weekly or does not take any medications.

 

  • Administered/Monitored by Lay Person(s) (D):  The individual needs assistance of a person without pharmacology training to either administer or monitor medications. This includes medication aides in assisted living facilities (certified but not licensed) and programmed medication dispensers.

 

  • Administered/Monitored by Professional Nursing Staff (D):  The individual needs licensed or professional health personnel to administer or monitor some or all of the medications. 

 

Rating Criteria for Behavior Pattern and Orientation: Behavior and Orientation are considered in combination for service authorization. To accurately rate Behavior and Orientation please use the crosswalk included as Attachment A in this manual.

 

Behavior Pattern is the manner of conducting oneself within one's environment.

 

Orientation is the awareness of an individual within his or her environment in relation to time, place, and person.

 

Behavior Pattern (PAS)

  • Appropriate (I):  The individual's behavior pattern is suitable or fitting to the environment. Appropriate behavior is of the type that adjusts to accommodate expectations in different environments and social circumstances. Behavior pattern does not refer to personality characteristics such as "selfish," "impatient," or "demanding," but is based on direct observations of the individual's actions.

 

  • Inappropriate Wandering, Passive, or Other: 

Wandering/Passive < weekly = (I);

Wandering/Passive Weekly or More = (d):

The individual's usual behavior is manifested in a way that does not present major management problems. Wandering is characterized by physically moving about aimlessly or mentally being non-focused. Passive behavior is characterized by a lack of awareness or interest in personal matters and/or in activities taking place in close proximity. Other characterizations of behavior such as impaired judgment, regressive behavior, agitation, or hallucinations that is not disruptive are included in this category.

 

  • Inappropriate Abusive, Aggressive, or Disruptive:

Abusive/Aggressive/Disruptive < Weekly = (D);

Abusive/Aggressive/Disruptive Weekly or More = (D): 

The individual’s behavior is manifested by acts detrimental to the life, comfort, safety, and/or property of the individual and/or others. Agitations, hallucinations, or assaultive behavior that is detrimental are included in this category and specified in the space provided.

 

  • Comatose (D):  refers to the semi-conscious or comatose (unconscious) state.

Orientation (PAS)

  • Oriented (I): The individual has no apparent problems with orientation and is aware of who he or she is, where he or she, the day of the week, the month, and people around him or her.
  • Disoriented-Some Spheres, Some of the Time (d): The individual sometimes has problems with one or two of the three cognitive spheres of person, place, or time. Some of the Time means there are alternating periods of awareness-unawareness.
  • Disoriented-Some Spheres, All of the Time (d): The individual is disoriented in one or two of the three cognitive spheres of person, place, and time. All of the time means this is the individual’s usual state.
  • Disoriented-All Spheres, Some of the Time (D): The individual is disoriented to person, place, and time periodically, but not always.
  • Disoriented-All Spheres, All of the Time (D): The individual is always disoriented to person, place, and time.
  • Comatose (D):     The individual is in a semi-comatose or unconscious state or is otherwise non-communicative.

Crosswalk for combination determination: Behavior and Orientation are considered as a combination for service authorization. Please see the chart below that provides the combinations that determine whether or not an individual is independent (I), semi-dependent (d), or dependent (D) in both behavior and orientation for the purposes of Screening for Medicaid-funded LTSS. This crosswalk has been provided as a quick pull reference sheet, Attachment A, for face to face assessments.

 

 

ORIENTATION PATTERN

BEHAVIOR PATTERN

Appropriate

Wandering/ Passive Less Than Weekly

Wandering/ Passive Weekly or More

Abusive/Aggressive/ Disruptive Less Than Weekly

Abusive/ Aggressive

/Disruptive Weekly or More

Oriented

I

I

I

d

d

Disoriented: Some spheres Some of the time

I

I

d

d

D

Disoriented: Some spheres All of the time

I

I

d

d

D

Disoriented: All spheres Some of the time

d

d

d

D

D

Disoriented: All

spheres All of the time

d

d

d

D

D

 

Comatose

D

D

D

D

D

Reminder: An individual must meet all criteria to meet NF LOC, i.e. the individual has limited functional capacity, medical or nursing needs, and is at imminent risk of NF placement within 30 days without services

 

Attachment B of this manual provides a worksheet for summarizing the results of the LTSS Screening and determining functional, medical or nursing need, and at-risk status of the individual.

CHILDREN’S SCREENING CRITERIA FOR MEDICAID-FUNDED LTSS

The Screening criteria for assessing a child’s eligibility for Medicaid reimbursement of LTSS consists of several components as follows:

 

  1. Functional capacity: evaluates a child’s ability to independently perform activities of daily living (ADLs), demonstrate mobility, joint motion, and medication administration, and assess behavior and orientation status as measured on the UAI.  The assessment considers how a child functions in a community environment and excludes all institutionally induced dependencies.  IADLs may also be assessed to assist in determining needs for community (non-Medicaid) resources.

 

  1. Medical or nursing needs: determines if the child meets the medical criteria for nursing facility level of care and/or admission.       

 

  1. In order to qualify and be authorized for Medicaid reimbursement for LTSS, the child must also be at risk for NF placement, or equivalent facility for children, within 30 days in the absence of the CCC Plus Waiver. “At Risk” also includes the need for the level of care provided in a hospital.

 

The CCC Plus Waiver may be an appropriate choice for children.  Prior to a NF placement or admission (or equivalent for children), the LTSS Screening team must also ensure that provision of services in a HCBS setting is considered before a NF placement is sought. 

 

Children may be screened for the CCC Plus Waiver while they are on the waiting list for the Building Independence (BI); Family & Individual Services (FIS); or Community Living (CL) Waivers.  However, the child must meet the criteria for the waivers for which they seek enrollment in order to be authorized for services. Please note that eligibility for CCC Plus Waiver or NF services does not indicate eligibility for one of the Developmental Disability (DD) Waivers nor is someone who is a participant in a DD waiver automatically eligible for CCC Plus Waiver or NF services.

 

Children are considered a household of one for the purposes of the CCC Plus Waiver financial determinations. 

 

It should be noted that the authorization for Medicaid-funded LTSS may be rescinded by the LTSS provider (including CCC Plus health plan or PACE) at any point in time that the child is determined to no longer meet the criteria for Medicaid-funded LTSS. 

 

Functional Capacity

Functional capacity is the degree of independence that a child, as age appropriate, or the child and caregiver as a unit, perform ADLs, joint motion, medication administration, and the individual’s behavior and orientation status as measured on the UAI.  

 

Functional capacity can be measured and is commonly used as a basis for differentiating levels of long-term services and supports. Child and caregiver as a unit is used to describe the usual caregiving responsibilities that are provided at certain ages by a caregiver (e.g. children under two as developmentally appropriate receive diaper changes, assistance with bathing, dressing, assistance with IADLS, etc.).  This capacity assessment should be conducted face-to-face and to the extent possible observed by the LTSS Screener.

 

A child may meet the functional capacity requirements for NF care when one of the following applies:

 

1.         Rated dependent in two or more of the ADLs, and also rated semi-dependent or dependent in Behavior Pattern and Orientation, and semi-dependent or dependent in Joint Motion or dependent in Medication Administration; or

 

2.         Rated dependent in five to seven of the ADLs and also rated dependent in Mobility; or

 

3.         Rated semi-dependent or dependent in two or more of the ADLs and also rated dependent in Mobility and Behavior Pattern and Orientation.

 

The following abbreviations are used on the UAI and mean:

 

I = independent

d= semi-dependent

D= dependent

 

Activities of Daily Living   (ADLs)

Bathing. Dressing. Toileting, Transferring

Rating

Without help

I

Mechanical Help (MH) only

d

Human Help only (HH)

D

MH & HH

D

Performed by others

D

Is not performed

D

Bowel Function

 

Continent

I

 

Incontinent less than weekly

d

 

External/In-dwelling device/Ostomy self-care

d

 

Incontinent weekly or more

D

 

Ostomy - not self-care

D

 

Bladder Function

 

Continent

I

 

Incontinent less than weekly

d

 

External/In-dwelling device/ Ostomy self-care

d

 

Incontinent weekly or more

D

 

External device - not self-care

D

 

Indwelling catheter - not self-care

D

 

Ostomy - not self-care

D

 

Eating/Feeding

 

Without help

I

 

Mechanical help (MH) only

d

 

Human help only (HH)

D

 

MH & HH

D

 

Spoon Fed

D

 

Syringe or Tube Fed

D

 

Tube fed by IV or clysis

D

 

Joint Functioning

 

 

Within normal limits or instability corrected

I

 

Limited motion

d

 

Instability - uncorrected or immobile

D

 

Mobility

 

 

Goes outside without help

I

 

Goes outside with Mechanical help (MH) only

d

 

Goes outside with Human help only (HH)

D

 

Goes outside with MH & HH

D

 

Confined - moves about

D

 

Confined – does not move about

D

 

Medication Administration

 

 

No medications

I

 

Self-administered – monitored less than weekly

I

 

By lay persons administered/monitored

 

D

 

By licensed/ professional nurse administered/ monitored

D

 

Orientation

 

 

Oriented

I

 

Disoriented – Some spheres, some of the time

d

 

Disoriented – Some spheres, all the time

d

 

Disoriented – All spheres, some of the time

D

 

Disoriented – All spheres, all of the time

D

 

Comatose

D

 

Behavior

 

 

Appropriate

I

 

Wandering/Passive-Less than Weekly

I

 

Wandering/Passive - Weekly or More

d

 

Abusive/Aggressive/Disruptive - Less than Weekly

D

 

Abusive/Aggressive/Disruptive - Weekly or More

D

 

Comatose

D

 

       

 

Medical or Nursing Needs

A child with medical or nursing needs is a child whose health needs require medical or nursing supervision or care above the level that could be provided through assistance with ADLs, medication administration, and general supervision and is not primarily for the care and treatment of mental diseases (12VAC30-60-303.D).  Medical or nursing supervision or care beyond this level is required when any one of the following describes the child’s need for medical or nursing supervision:

 

  1. The child’s medical condition requires observation and assessment to ensure evaluation of the child’s need for modification of treatment or additional medical procedures to prevent destabilization, and the child, as developmentally appropriate, has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals; or

 

  1. Due to the complexity created by the child’s multiple, inter-related medical conditions, the potential for the child’s medical instability is high or medical instability exists; or

 

  1. The child requires at least one ongoing medical or nursing service.  Ongoing means that the medical/nursing needs are continuing, not temporary, or where the individual is expected to undergo or develop changes with increasing severity in status.  “Ongoing” refers to the need for daily direct care and/or supervision by a licensed nurse that cannot be managed on an outpatient basis.

 

If applicable, specify the ongoing medical or nursing need in  eMLS.  An individual who is receiving rehabilitation services and/or special medical procedures does not automatically have ongoing medical or nursing needs as there should be documentation to support the rehabilitation services and/or special medical procedures such as physician orders or progress notes.

 

Note:  NF LOC for an individual is not determined by an individual’s age, nor specific diagnosis or therapy used.

 

The following is a non-exclusive list of medical or nursing services that MAY indicate a need for medical or nursing supervision or care:

 

  1. Application of aseptic dressings;

 

  1. Routine catheter care;

 

  1. Respiratory therapy;

 

  1. Supervision for adequate nutrition and hydration for children who show clinical evidence of malnourishment or dehydration or have a recent history of weight loss or inadequate hydration which, if not supervised, would be expected to result in malnourishment or dehydration (this also includes observation and supervision of special diets, e.g. diabetic, renal, cardiac, etc.);

 

  1. Therapeutic exercise and positioning;

 

  1. Routine care of colostomy or ileostomy or management of neurogenic bowel and bladder;

 

  1. Use of physical (e.g., side rails, Posey vests, geri-chairs, locked units) or chemical restraints (e.g. overuse of sedatives), or both;

 

  1. Routine skin care to prevent pressure ulcers for children who are immobile or whose medical condition increases the risk of skin breakdown;

 

  1. Care of small uncomplicated pressure ulcers and local skin rashes;

 

  1. Management of those with sensory, metabolic, or circulatory impairment with demonstrated clinical evidence of medical instability;

 

  1. Chemotherapy;

 

  1. Radiation;

 

  1. Dialysis including observation of and care of the access port;

 

  1. Suctioning;

 

  • Tracheostomy care;

 

  1. Infusion therapy;

 

  1. Oxygen;

 

Examples of Medical or Nursing Needs:

 

  • Drainage Tubes

 

  • End-Stage Disease

 

  • Naso-gastric Tube Feeding

 

  • Total Parenteral Nutrition management and care as directed

 

  • Severe Daily Pain Management as directed by physician

 

  • Transplant management and care as directed

 

  • Uncontrolled Seizures management and observation

 

  • Use of Ventilator

 

Please note that in rare circumstances, a medical situation that requires complex medical care or equipment to sustain life may be a reason for an individual to meet NF LOC even when the individual does not meet functional capacity criteria.  In these instances, a DMAS-108 (for adults) or a DMAS-109 (for children) would be completed.  Additional information is found under Private Duty Nursing (PDN) services.

 

PDN exception note: If the child is rated dependent in some functional limitations, but does not meet the functional capacity requirements, it should be determined if the individual requires the daily direct services or supervision of a licensed nurse for PDN services that cannot be managed on an outpatient basis (e.g. clinic, physician visits, home health services).

 

Rating Criteria for Children’s Assessments

 

It is mandatory, when assessing children, to use the rating criteria below that indicates the child’s functional capacity and medical/nursing need.  When reviewing children for dependencies, Screening teams should rate at the highest dependency level which accurately assesses the child’s needs and allows the child (and their caregiver) to perform the activity safely, reliably and completely from beginning to end.

 

Please note that age-appropriate rating criteria involves the child and the caregiver as a unit.  The concept of the child and the caregiver as a unit applies only to children.

 

Rating Criteria for Bathing:

  

Bathing entails getting in and out of the tub, preparing the bath (e.g., turning on the water), actually washing oneself, and towel drying. Some individuals may report various methods of bathing that constitute their usual pattern. For example, they may bathe themselves at a sink or basin five days a week, but take a tub bath two days of the week when an aide assists them. The questions refer to the method used most or all of the time to bathe the entire body.

 

Screening considerations for children, as age appropriate, include: safety concerns such as seizure activity; balance; head positioning; awareness of water depth, temperature, or surroundings (i.e. location of faucet); and/or other characteristics that make bathing very difficult such as complex medical needs or equipment.  If the child’s situation includes any of these, rate accordingly, as age appropriate.

 

  • Does Not Need Help (I):  The child and caregiver as a unit, or the child, as age appropriate, gets in and out of the tub or shower, turns on the water, bathes entire body, or takes a full sponge bath at the sink. 
  • Children younger than 12 months are developmentally expected to be totally dependent on another person/caregiver for bathing. If there are no other complex medical needs or equipment, then the child is rated as independent. 
  • Children age 1 to 4 are developmentally expected to physically participate in bathing but require caregiver supervision, physical assistance, and help getting in and out of the tub.  If the child and caregiver as a unit can achieve this task; the child is participating as appropriate; and there are no other complex medical needs or equipment, then they are independent.
  • Children age 5 to 18 years are developmentally expected to physically and cognitively perform all essential components of bathing safely and without assistance.  The child should be able to bathe independently (if they are not able to achieve this task, then refer to one of the other functional capacities listed below and rate accordingly).

 

  • Mechanical Help Only (d):  The child and caregiver as a unit, or the child, as age appropriate, needs equipment or an assistive device such as a shower/tub chair/stool, pedal/knee controlled faucet, grab bars, long-handled brush, and/or a mechanical lift to complete the bathing process.  This does not include a baby tub for infants. 

 

  • Human Help Only (D):  

 

Supervision (Verbal Cues, Prompting):  The child, needs supervision, prompting and/or verbal cues to safely complete washing the entire body. Developmental stage should be considered as to what is appropriate.

 

Physical Assistance (Set-up, Hands-On Care):  The child requires someone to fill the tub or bring water to the child, wash part of the body, help the child get in and out of the tub or shower, and/or help the child towel dry.  Developmental stage should be considered as to what is appropriate.

 

Children who only need help to wash their backs or feet would not be included in this category. 

 

  • Children younger than 12 months are developmentally expected to be totally dependent on another person/caregiver for bathing.  If there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need, then this category may be appropriate.   
  • Children age 1 to 4 are developmentally expected to physically participate in bathing but require caregiver supervision, physical assistance, and help getting in and out of the tub.  If the child and caregiver as a unit can achieve this task; the child is participating; and there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need, then this category may be appropriate.
  • Children age 5 to 18 years are developmentally expected to physically and cognitively perform all essential components of bathing safely and without assistance.  The child should be able to bathe independently (if they are not able achieve this task then this category may be appropriate).

 

Mechanical and Human Help (D):   The child usually needs equipment or a device and requires assistance of other(s) as defined above under Mechanical Help and Human Help to bathe. Developmental stage should be considered as to what is appropriate.

  • Children younger than 12 months are developmentally expected to be totally dependent on another person/caregiver for bathing.  If the child and caregiver as a unit can achieve this task and there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need, then this category may be appropriate.   
  • Children age 1 to 4 are developmentally expected to physically participate in bathing but require caregiver supervision, physical assistance, and help in and out of the tub.  If the child and caregiver as a unit can achieve this task; the child is participating; and there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need, then this category may be appropriate.
  • Children age 5 to 18 years are developmentally expected to physically and cognitively perform all essential components of bathing safely and without assistance.  The child should be able to bathe independently (if they are not able achieve this task then this category may be appropriate).

 

Performed by Others (D):  The child is completely bathed by other(s) and does not take part in the activity at all.  Developmental stage should be considered as to what is appropriate.

  • Children younger than 12 months are developmentally expected to be totally dependent on another person/caregiver for bathing.  If there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need, then this category may be appropriate.   
  • Children age 1 to 4 are developmentally expected to physically participate in bathing but require caregiver supervision, physical assistance, and help in and out of the tub.  If the child and caregiver as a unit can achieve this task; the child is participating; and there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need, then this category may be appropriate.
  • Children age 5 to 18 years are developmentally expected to physically and cognitively perform all essential components of bathing safely and without assistance.  The child should be able to bathe independently (if they are not able achieve this task then this category may be appropriate).

 

Rating Criteria for Dressing:

 

Dressing is the process of getting clothes from closets and/or drawers, putting them on, fastening, and taking them off. Clothing refers to clothes, braces and artificial limbs worn daily.  Individuals who wear pajamas or gown with robe and slippers as their usual attire are considered dressed. 

 

Screening considerations for children, as age appropriate, include:  safety concerns such as seizure activity; balance; awareness to surroundings; proneness to skin irritation/allergies; and/or other characteristics that make dressing very difficult and may include complex medical needs or equipment maybe considered. If the child’s situation includes any of these, rate accordingly, as age appropriate.

 

 

  • Does Not Need Help (I):  The child and caregiver as a unit, or the child, as age appropriate, usually dresses without the help from others.  If the only help the child received is tying shoes, do not count as needing help.
  • Children younger than 12 months of age are developmentally expected to be totally dependent on another person/caregiver for dressing. If there are no other complex medical needs or equipment, then the child is independent. 
  • Children age 1 to 4 are developmentally expected to participate in dressing, which includes placing arms in sleeves or legs into pants, pulling at hats, socks or mittens, and require supervision, reminders, physical assistance, help with fasteners or shoes, and/or selecting clothes. If the child and caregiver as a unit can achieve this task; the child participates; and there are no other complex medical needs or equipment, then the child is rated independent. 
  • Children age 5 to 18 years are developmentally expected to be independent and able to physically and cognitively perform all essential components of dressing, safely and appropriately to weather, and without assistance (if they are not able to achieve this task, then refer to one of the other functional capacities listed below and rate accordingly).

 

  • Mechanical Help Only (d):  The child, as age appropriate, usually needs equipment or adaptive devices such as a long-handled shoehorn, zipper pulls, specially designed clothing or a walker with an attached basket to complete the dressing process.

 

  • Human Help Only (D):

 

Supervision (Verbal Cues, Prompting):    The child usually requires prompting and/or verbal cues to complete the dressing process.  Developmental stage should be considered as to what is appropriate.

 

Physical Assistance (Set-up, Hands-On Care):  The child usually requires assistance from another person who helps in obtaining clothing, fastening hooks, putting on clothes or artificial limbs, etc. Developmental stage should be considered as to what is appropriate.

 

If the only help the child needs is someone tying shoes, do not count as needing help.

 

  • Children younger than 12 months are developmentally expected to be totally dependent on another person/caregiver for dressing.  If there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need, then this category may be appropriate.
  • Children age 1 to 4 are developmentally expected to participate in dressing which includes placing arms in sleeves or legs into pants, pulling on hats, socks or mittens, and require supervision, reminders, physical assistance, help with fasteners or shoes, and/or selecting clothes. If the child and caregiver as a unit can achieve this task; the child participates; and there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need, then this category may be appropriate.
  • Children ages 5 to 18 years are developmentally expected to be independent and able to perform all essential components of safely dressing and dressing appropriately to the weather, and without assistance (if the child is not able to achieve this task, then this category may be appropriate).

 

  • Mechanical and Human Help (D):  Child usually needs equipment or a device and requires assistance of other(s) to dress as defined above under Mechanical Help and Human Help to dress.
  • Children younger than 12 months are developmentally expected to be totally dependent on another person/caregiver for dressing.  If there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need, then this category may be appropriate.
  • Children age 1 to 4 are developmentally expected to participate in dressing which includes placing arms in sleeves or legs into pants, pulling on hats, socks or mittens, and require supervision, reminders, physical assistance, help with fasteners or shoes, and/or selecting clothes. If the child and caregiver as a unit can achieve this task; the child participates; and there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need, then this category may be appropriate.
  • Children ages 5 to 18 years are developmentally expected to be independent and able to perform all essential components of safely dressing and dressing appropriately to the weather, and without assistance (if the child is not able to achieve this task, then this category may be appropriate).

 

  • Performed by Others (D):  Child is completely dressed by another individual and does not take part in the activity at all.
  • Children younger than 12 months are developmentally expected to be totally dependent on another person/caregiver for dressing.  If the child and caregiver as a unit can achieve this task and there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need, then this category may be appropriate.
  • Children age 1 to 4 are developmentally expected to participate in dressing which includes lacing arms in sleeves or legs into pants, pulling at hats, socks or mittens, and require supervision, reminders, physical assistance, help with fasteners or shoes, and/or selecting clothes. If the child and caregiver as a unit can achieve this task; the child participates; and there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need, then this category may be appropriate.
  • Children ages 5 to 18 years are developmentally expected to be independent and able to perform all essential components of dressing safely and dressing appropriately to weather, and without assistance (if they are not able to achieve this task then this category may be appropriate).

 

  • Is Not Performed (D):  Refers only to children confined to bed who are considered not dressed. 

Rating Criteria for Toileting:

 

Toileting is the ability to get to and from the bathroom, get on/off the toilet, clean oneself, manage clothes and flush. A commode at any site may be considered the "bathroom" only if in addition to meeting the criteria for "toileting" the individual empties, cleanses, and replaces the receptacle, such as the bed pan, urinal or commode, without assistance from other(s).

 

This category includes appropriate use and disposal of incontinent supplies or pads by the child.

 

Screening considerations for children, as age appropriate, include:  safety concerns such as frequent infections; hygiene needs; utilizes incontinence supplies; and/or other characteristics that make toileting very difficult including complex medical needs or equipment.  If the child’s situation includes any of these, rate accordingly, as age appropriate.

 

  • Does Not Need Help (I):  The child and caregiver as a unit, or the child, as age appropriate, achieves the toileting process.  The child uses the bathroom, cleans self, and arranges clothes without the help from others.  The child appropriately uses and disposes of incontinent supplies or pads.

 

  • Children from birth to 3 years of age are developmentally expected to be dependent on another person/caregiver for assistance in toileting or diapering.  Children starting at 24 months of age (2 years of age) are expected to begin toilet training.  If the child and caregiver as a unit can achieve the task and there are no other complex medical needs or equipment, then the child is rated independent.
  • Children 4-5 years of age are developmentally expected to need intermittent supervision, cuing, minor physical assistance, and may have occasional night-time bedwetting and accidents during waking hours.  Children starting at 24 months of age (2 years of age) are expected to be toilet training.  If the child and caregiver as a unit can achieve this task and there are no other complex medical needs or equipment, then the child is rated independent. 
  • Children 6 to 18 years of age are developmentally expected to be independent and able to physically and cognitively perform all essential components of toileting safely and without assistance except for children aged 6 that may need help with wiping. If the child is not able to achieve these tasks, then refer to one of the other functional capacities listed below and rate accordingly. 

 

  • Mechanical Help Only (d):  The child and caregiver as a unit, or the child, as age appropriate, needs grab bars, step stools, transfer board, handrails, walkers, wheelchairs, and/or canes for support during the toileting process.  This also includes children who use the bathroom without help during the day and uses a bedpan, urinal, or bedside commode without help during the night and can empty this receptacle without assistance. This category includes use and disposal of incontinent supplies or pads by the child.  This does not include a “potty” chair used for toilet training children under 6 years of age. 

 

  • Human Help Only (D):

 

Supervision (Verbal Cues, Prompting):    The child, as age appropriate, usually requires prompting and/or verbal cues to complete the toileting process.  Children 6 years of age and older who need supervision would receive this category rating. 

 

Physical Assistance (Set-up, Hands-On Care):  The child, as age appropriate, usually requires assistance from another person who helps in getting to/from the bathroom, adjusting clothes, transferring on and off the toilet, cleansing after elimination or assists with use and disposal of incontinence supplies or pads.  The child participates in the activity.

 

  • Children younger than 4 years of age are developmentally expected to be dependent on another person/caregiver for assistance in toileting or diapering.  Children starting at 24 months of age (2 years of age) are expected to begin toilet training.   If the child and caregiver as a unit can achieve this task and there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need then this category may be appropriate.
  • Children 4-5 years of age are developmentally expected to need intermittent supervision, cuing, minor physical assistance, and may have occasional night-time bedwetting and accidents during waking hours.  Children starting at 24 months of age (2 years of age) are expected to begin toilet training.  If the child and caregiver as a unit can achieve these tasks and there are no other complex medical needs or equipment, then the child is independent. If the child has a complex medical need then this category may be appropriate.   
  • Children 6 to 18 years of age are developmentally expected to be independent and able to physically and cognitively perform all essential components of toileting safely and without assistance except for children aged 6 that may need help with wiping.  If the child is not able to achieve these tasks then this category may be appropriate. This category includes supervision and/or physical assistance with incontinent supplies or pads. 

 

  • Mechanical and Human Help (D):  The child usually needs equipment or a device and requires assistance of other(s) as defined above under Mechanical Help and Human Help to toilet.
  • Children younger than 4 years of age are developmentally expected to be dependent on another person/caregiver for assistance in toileting or diapering.  Children starting at 24 months of age (2 years of age) are expected to begin toilet training.   If the child and caregiver as a unit can achieve these tasks and there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need, then this category may be appropriate.
  • Children 4-5 years of age are developmentally expected to need intermittent supervision, cuing, minor physical assistance, and may have occasional night-time bedwetting and accidents during waking hours.  Children starting at 24 months of age (2 years of age) are expected to begin toilet training.  If the child and caregiver as a unit can achieve these tasks and there are no other complex medical needs or equipment, then the child is rated independent. If the child has a complex medical need, then this category may be appropriate.   
  • Children 6 to 18 years of age are developmentally expected to be independent and able to physically and cognitively perform all essential components of toileting safely and without assistance except for children aged 6 that may need help with wiping.  If the child is not able to achieve the tasks of toileting, then this category may be appropriate. 

 

  • Performed by Others (D):  The child age 5 and over, uses the bathroom, but is totally dependent on another's assistance in getting to/from the bathroom, adjusting clothes, transferring on and off the toilet, cleansing after elimination and/or is totally dependent on another’s assistance with the use and disposal of incontinent supplies or pads, and the child does not participate in the activity at all, then this category is chosen.
  • Children younger than 4 years of age are developmentally expected to be dependent on another person/caregiver for assistance in toileting or diapering.  Children starting at 24 months of age (2 years of age) are expected to begin toilet training.   If the child and caregiver as a unit can achieve this task and there are no other complex medical needs or equipment, then the child is rated independent.  If the child has a complex medical need, then this category may be appropriate.
  • Children 4-5 years of age are developmentally expected to need intermittent supervision, cuing, minor physical assistance, and may have occasional night-time bedwetting and accidents during waking hours.  Children starting at 24 months of age (2 years of age) are expected to begin toilet training.  If the child and caregiver as a unit can achieve this task and there are no other complex medical needs or equipment, then the child is rated independent. If the child has a complex medical need, then this category may be appropriate.
  • Children 6 to 18 years of age are developmentally expected to be independent and able to physically and cognitively perform all essential components of toileting safely and without assistance except for children aged 6 that may need help with wiping.  If the child is not able to achieve the tasks of toileting, then this category may be appropriate.  This category includes total assistance by others with incontinent supplies or pads. 

 

  • Is Not Performed (D):  The child age 5 and over does not use the bathroom or go to/from the bathroom, adjust clothes, transfer on and off the toilet, cleanse after elimination, or independently use and dispose of incontinent supplies or pads.  

 

 

 

Rating Criteria for Transferring:

 

Transferring means the individual’s ability to move between the bed, chair, and/or wheelchair. If a person needs help with some transfers but not all, rate assistance at the highest level.

 

Screening considerations for children, as age appropriate, include:  safety concerns such as the child’s ability to move between the bed, chair, and/or wheelchair.  If the child’s situation includes safety concerns, rate accordingly, as age appropriate.

 

 

  • Does Not Need Help (I):  The child and caregiver as a unit, or the child, as age appropriate, achieves the transferring process without human assistance or use of equipment.
  • Children from birth to 5 years of age are developmentally expected to need total dependence or assistance from a caregiver in transferring.  If the child and caregiver as a unit are able to achieve the transferring process, then the child is rated independent.
  • Children age 6 years of age and older are developmentally expected to be independent and able to physically and cognitively perform all essential components of transferring safely, and without assistance.  If the child is not able to achieve this task, then refer to one of the other functional capacities listed below and rate accordingly.

 

  • Mechanical Help Only (d):  The child and caregiver as a unit, or the child, as age appropriate, usually needs equipment or a device, such as lifts, hospital beds, sliding boards, pulleys, trapezes, railings, walkers or the arm of a chair, to safely transfer, and the child manages these devices without the aid of another person.

 

  • Human Help Only (D): 

 

Supervision (Verbal Cues, Prompting):  The child, as age appropriate, usually needs verbal cues or guarding to safely transfer. 

 

Physical Assistance (Set-up, Hands-On Care): The child and caregiver as a unit, or the child, as age appropriate, usually requires the assistance of another person who lifts some of the individual's body weight and provides physical support in order for the child to safely transfer.

 

  • Children from birth to 5 years of age are developmentally expected to need assistance from a caregiver in the transferring process. If the child and caregiver as a unit are able to achieve the transferring process, then the child is rated as independent.
  • Children age 6 years of age and older are developmentally expected to be independent and able to physically and cognitively perform all essential components of the task safely and without assistance. If the child is not able to achieve in the task then this category may be appropriate.

 

  • Mechanical and Human Help (D):  The child and caregiver as a unit, or the child, as age appropriate, usually needs equipment or a device and requires the assistance of other(s) to transfer as defined above under Mechanical Help and Human Help to transfer.
  • Children from birth to 5 years of age are developmentally expected to need assistance from a caregiver in the transferring process. If the child and caregiver as a unit are able to achieve the transferring process, then the child is rated as independent.
  • Children age 6 years of age and older are developmentally expected to be independent and able to physically and cognitively perform all essential components of the task safely and without assistance. If the child is not able to achieve in the task, then this category may be appropriate.

 

  • Performed By Others (D):  The child and caregiver as a unit, or the child, as age appropriate, is usually lifted out of the bed and/or chair by another person and does not participate in the process.  If the child does not bear weight on any body part in the transferring process; he/she is not participating in the transfer.  Individuals who are transferred with a mechanical lift and do not participate are included in this category.
  • Children from birth to 5 years of age are developmentally expected to need assistance from a caregiver in the transferring process. If the child and caregiver as a unit are able to achieve the transferring process and are not using a mechanical lift, then the child is rated as independent.
  • Children age 6 years of age and older are developmentally expected to be independent and able to physically and cognitively perform all essential components of the task safely and without assistance. If the child is not able to achieve in the task, then this category may be appropriate.

 

  • Is Not Performed (D):  The child is confined to the bed.

 

Rating Criteria for Eating/Feeding:

 

Eating/Feeding is the process of getting food/fluid by any means into the body. This activity includes cutting food, transferring food from a plate or bowl into the individual's mouth, opening a carton and pouring liquids, and holding a glass to drink. This activity is the process of eating food after it is placed in front of the individual.

 

Screening considerations for children, as age appropriate, include:  safety concerns such as the child’s ability to regulate amount of intake; chew; swallow; monitoring to prevent choking or aspiration; utilize utensils; seizure activity; dietary restrictions; allergies; eating disorders; requires more than one hour per feeding for ages birth to 37 months (3 years and 1 month); requires more than 3 hours per feeding for ages 5 to 18; has other forms of feeding such as tube or intravenous; or other serious complications.  If the child’s situation includes any of these, rate accordingly, as age appropriate.

 

 

  • Does Not Need Help (I):  The child and caregiver as a unit, or the child, as age appropriate, is able to perform all of the activities of eating/feeding without using equipment or the supervision or assistance of another.
  • Children from birth to 12 months of age are developmentally expected to be dependent on another person/caregiver for eating/feeding and monitoring for safety.  If the child and caregiver as a unit can achieve the tasks of eating/feeding and there are no other complex medical needs, equipment, or age appropriate risk as stated above under considerations, then the child is rated independent. 
  • Children from ages 1-4 are developmentally expected to physically participate and may need constant supervision for safety and/or assistance in eating/feeding.  If the child and caregiver as a unit can achieve the tasks of eating/feeding and there are no other complex medical needs, equipment, or risk as stated above under considerations, then the child is rated as independent. 
  • Children ages 5-18 are developmentally expected to physically and/or cognitively perform all essential components of eating/feeding safely, and without assistance, after food is placed in front of the child.  If the child is not able to independently eat/feed, then refer to one of the other functional capacities listed below and rate accordingly.

 

  • Mechanical Help Only (d):  The child, as age appropriate, usually needs equipment or a device, such as hand splints, adapted utensils, and/or nonskid plates, in order to complete the eating/feeding process.  A child needing mechanically adjusted diets (pureed food) and/or food chopped would be rated this category.

  

  • Human Help Only (D): 

 

Supervision (Verbal Cues, Prompting):  The child as age appropriate, feeds self, but needs verbal cues and/or prompting to initiate and/or complete the eating/feeding process. 

 

Physical Assistance (Set-up, Hands-On Care):  The child and caregiver as a unit, or the child, as age appropriate, needs assistance to bring food to the mouth, butter bread, open cartons and/or pour liquid due to an actual physical or mental disability. 

 

This category must not be checked if the child is able to feed himself but it is more convenient for the caregiver to complete the activity.

 

  • Children from birth to 12 months of age are developmentally expected to be dependent on another person/caregiver for eating/feeding and monitoring for safety.  If the child and caregiver as a unit can achieve the tasks of eating/feeding and there are no other complex medical needs, equipment, or age appropriate risk as stated above under considerations, then the child is rated independent. 
  • Children from ages 1-4 are developmentally expected to physically participate and may need constant supervision for safety and/or assistance in eating/feeding.  If the child and caregiver as a unit can achieve the tasks of eating/feeding and there are no other complex medical needs, equipment, or risk as stated above under considerations, then the child is rated as independent. 
  • Children ages 5-18 are developmentally expected to physically and/or cognitively perform all essential components of eating/feeding safely, and without assistance, after food is placed in front of the child.  If the child is not able to independently eat/feed, then refer to one of the other functional capacities listed below and rate accordingly.

 

  • Mechanical and Human Help (D):  The child and caregiver as a unit, or the child, as age appropriate, usually needs equipment or a device and requires assistance of other(s) to eat as defined above under Mechanical Help and Human Help.
  • Children from birth to 12 months of age are developmentally expected to be dependent on another person/caregiver for eating/feeding and monitoring for safety.  If the child and caregiver as a unit can achieve the tasks of eating/feeding and there are no other complex medical needs, equipment, or age appropriate risk as stated above under considerations, then the child is rated independent. 
  • Children from ages 1-4 are developmentally expected to physically participate and may need constant supervision for safety and/or assistance in eating/feeding.  If the child and caregiver as a unit can achieve the tasks of eating/feeding and there are no other complex medical needs, equipment, or risk as stated above under considerations, then the child is rated as independent. 
  • Children ages 5-18 are developmentally expected to physically and/or cognitively perform all essential components of eating/feeding safely, and without assistance, after food is placed in front of the child.  If the child is not able to independently eat/feed, then refer to one of the other functional capacities listed below and rate accordingly.

 

  • Performed By Others (D):  This category included children who are spoon fed; fed by syringe or tube, or children who are fed intravenously (IV). 

Spoon fed means the child does not bring any food to his mouth and is fed completely by others. 

Fed by syringe or tube means the child usually is fed a prescribed liquid diet via a feeding syringe, NG-tube (tube from the nose to the stomach) or G-tube (opening into the stomach).

Fed by I.V. means the child usually is fed a prescribed sterile solution intravenously. 

Total parenteral nutrition (TPN) is the administration of a nutritionally adequate solution through an indwelling catheter into the superior vena cava. 

 

  • Children from birth to 12 months of age are developmentally expected to be dependent on another person/caregiver for eating/feeding and monitoring for safety. This may include the child being spoon fed by a caregiver or learning to self-feed.  If the child and caregiver as a unit can achieve the tasks of eating/feeding, then the child is rated as independent.  If the child has a complex medical need or risk as stated above, then this category may be appropriate.    
  • Children from ages 1-4 are developmentally expected to physically participate and may need constant supervision for safety and/or assistance in eating/feeding.  If the child and caregiver as a unit are able to achieve the tasks of eating/feeding, then the child is rated as independent.  If the child has a complex medical need or risk as stated above, then this category may be appropriate.    
    • Children ages 5-18 are developmentally expected to physically and/or cognitively perform all essential components of eating/feeding safely, and without assistance, after food is placed in front of the child.  If the child has a complex medical need or risk as stated above, then this category may be appropriate.    

 

Rating Criteria for Bowel:

 

Bowel continence is the physiological process of elimination of feces.

 

Continence is the ability to control bowel elimination. Incontinence may have one of several different causes, including specific disease processes and side effects of medications. Helpful questions include, "Do you get to the bathroom on time?"; "How often do you have accidents?”, and "Do you use pads or diapers?"

 

  • Does Not Need Help (I):  This category includes age appropriate behavior:

1) The child voluntarily controls the elimination of feces. OR

2) If the child is on a bowel program and never empties his or her bladder without stimulation or a specified bowel regimen, then the child is rated as independent.  The bowel/bladder training is noted under medical/nursing needs because in this case, there is no voluntary elimination; evacuation is planned.

If a child on a bowel regimen also has occasions of bowel incontinence, then he or she would be rated as incontinent, either less than weekly or weekly or more. OR

3) If a child uses incontinent supplies such as briefs, pads or diapers and can independently change and dispose of items as age appropriate, then the child is rated as independent.

 

  • Children younger than 4 years of age are developmentally expected to need help with toileting and diapering.  If the child can have a bowel movement without the use of a medical or mechanical intervention, then the child is rated independent.
  • Children 4-5 years of age are developmentally expected to need help with toileting and may have occasional accidents during waking hours (this is not considered incontinence).   If the child can have a bowel movement without the use of a medical or mechanical intervention, then the child is rated as independent.
  • Children 6 to 18 years of age are expected to voluntarily control the elimination of feces.  If the child can empty his or her bowel without the use of medical or mechanical intervention, then the child is rated as independent. For children who use incontinence supplies such as briefs, pads, or diapers for involuntary elimination of feces and who are able to properly use or dispose of the items, then the child is rated independent.  If the child is not able to achieve control of elimination and cannot properly use or dispose of incontinence supplies, then refer to one of the other functional capacities listed below and rate accordingly.

 

  • Incontinent Less than Weekly [does not occur every week] (d):  The child has involuntary elimination of feces but it does not occur every week (e.g., every other week).  The individual is rated as “incontinent less than weekly.” 
  • Children younger than 4 years of age are developmentally expected to need help with toileting and diapering.  If the child can have a bowel movement without the use of a medical or mechanical intervention, then the child is rated independent.
  • Children 4-5 years of age are developmentally expected to need help with toileting and may have occasional accidents during waking hours (this is not considered incontinence). If the child can have a bowel movement without the use of a medical or mechanical intervention, then the child is rated as independent.
  • Children 6 to 18 years of age are expected to voluntarily control the elimination of feces.  If the child can empty his or her bowel without the use of medical or mechanical intervention, then the child is rated as independent.  If the child is not able to maintain continence, then this category may be appropriate. For children who use incontinence supplies such as briefs, pads, or diapers for involuntary elimination of feces and who are unable to properly use or dispose of the items, then this category may be appropriate.

 

  • Ostomy - Self-Care (d):   The child has an artificial anus established by an opening into the colon (colostomy) or ileum (ileostomy) and he independently cares for the ostomy, stoma, and skin cleansing, dressing, application of appliance, irrigation, etc. and if needed with ostomy, can appropriately change and dispose of incontinence supplies used. 
  • This category should only be used if the child can complete all components of this task independently.

 

  • Incontinent Weekly or More [Occurring at least once a week or more] (D):  The child has involuntary elimination of feces at least once a week or more.  Includes children who use incontinence supplies such as briefs, pads, or diapers for involuntary elimination of feces occurring at least once a week or more and, as age appropriate, cannot correctly use or dispose of incontinence supplies
  • Children younger than 4 years of age are developmentally expected to need help with toileting and diapering.  If the child can have a bowel movement without the use of a medical or mechanical intervention, then the child is rated independent.
  • Children 4-5 years of age are developmentally expected to need help with toileting and may have occasional accidents during waking hours (this is not considered incontinence).   If the child can have a bowel movement without the use of a medical or mechanical intervention, then the child is rated as independent.
  • Children 6 to 18 years of age are expected to voluntarily control the elimination of feces.  If the child can empty his or her bowel without the use of medical or mechanical intervention, then the child is rated as independent.  If the child is not able to maintain continence, then this category may be appropriate. For children who use incontinence supplies such as briefs, pads, or diapers for involuntary elimination of feces and who are unable to properly use or dispose of the items, then this category may be appropriate.

 

  • Ostomy - Not Self-Care (D):  The child has an artificial anus established by an opening into the colon (colostomy) or ileum (ileostomy) and another person cares for the ostomy, stoma, skin cleansing, dressing, application of appliance, irrigations, etc. and may also need assistance with the changing and appropriate disposal of incontinence supplies. 
  • This category should be used if the child cannot complete all components of this task independently.

 

Rating Criteria for Bladder:

 

Bladder continence is the physiological process of elimination of urine.

 

Continence is the ability to control urination (bladder). Incontinence may have one of several different causes, including specific disease processes and side effects of medications. Helpful questions include, "Do you get to the bathroom on time?"; "How often do you have accidents?”, and "Do you use pads or diapers?"

 

  • Does Not Need Help (I):  This category includes:

1) The child voluntarily empties his or her bladder. OR

2) Children on dialysis who have no urine output would be rated as independent as the child does not perform this process.  Dialysis will be noted under medical/nursing needs. OR

3) Similarly, children who perform the Crede method for himself or herself for bladder elimination would also be rated as independent.  OR

4) As age appropriate, the child uses incontinent supplies such as briefs, pads or diapers and can independently change and dispose of them appropriately, the child is rated as independent.

  • Children younger than 4 years of age are developmentally expected to need help with toileting and diapering.  If a child falls into this age group, the child is rated as independent unless the child has some other complex medical need such as an external device, indwelling catheter, or ostomy.
  • Children 4-5 years of age are developmentally expected to need help with toileting and may have occasional accidents during waking hours (this is not considered incontinence).  If a child falls into this age group, the child is rated as independent unless the child has some other complex medical need such as an external device, indwelling catheter, or ostomy.
    • Children 6 to 18 years of age are expected to voluntarily control the elimination of urine and can empty his or her bladder.  If a child uses incontinent supplies such as briefs, pads or diapers and can independently change and dispose of them appropriately, then the child is rated as independent.  If a child falls into this age group, the child is rated as independent unless the child has some other complex medical need such as an external device, indwelling catheter, or ostomy.

 

  • Incontinent Less than Weekly [does not occur every week] (d):  The child has involuntary emptying or loss of urine but it does not occur every week (e.g., every other week). 
  • Children younger than 4 years of age are developmentally expected to need help with toileting and diapering.  If a child falls into this age group, the child is rated as independent unless the child has some other complex medical need such as an external device, indwelling catheter, or ostomy.
  • Children 4-5 years of age are developmentally expected to need help with toileting and may have occasional accidents during waking hours (this is not considered incontinence).  If a child falls into this age group, the child is rated as independent unless the child has some other complex medical need such as an external device, indwelling catheter, or ostomy.
  • Children 6 to 18 years of age are expected to voluntarily control the elimination of urine and can empty his or her bladder. If the child is not capable of maintaining continence or utilizing incontinence supplies such as briefs, pads, or diapers, then this category may be appropriate.

  

  • External Device, Indwelling Catheter, or Ostomy - Self Care (d):  The child has an urosheath or condom with a receptacle attached to collect urine (external catheter); a hollow cylinder passed through the urethra into the bladder (internal catheter), a surgical procedure that establishes an external opening into the ureter(s) (ostomy) or may also include in and out catheterizations occurring multiple times a day (not indwelling).  The child completely cares for urinary devices (changes the catheter or external device, irrigates as needed, empties and replaces the receptacle) and the skin surrounding the ostomy.  This includes children who use any of these devices and may also need to use incontinence supplies such as briefs, pads, or diapers but can correctly change and dispose of them.
  • This category should only be used if the child can complete all components of this task independently.

 

  • Incontinent Weekly or More [Occurring once a week or more] (D):  The child has involuntary emptying or loss of urine at least once a week or more.
      • Children younger than 4 years of age are developmentally expected to need help with toileting and diapering.  If a child falls into this age group, the child is rated as independent unless the child has some other complex medical need such as an external device, indwelling catheter, or ostomy.
      • Children 4-5 years of age are developmentally expected to need help with toileting and may have occasional accidents during waking hours (this is not considered incontinence).  If a child falls into this age group, the child is rated as independent unless the child has some other complex medical need such as an external device, indwelling catheter, or ostomy.
  • Children 6 to 18 years of age are expected to voluntarily control the elimination of urine and can empty his or her bladder. If they are not capable of maintaining continence, then this category may be appropriate.   This includes children who use incontinence supplies such as briefs, pads, or diapers for involuntary emptying or loss of urine occurring at least once a week or more and who cannot correctly change or dispose of the items.

 

  • External Device - Not Self-Care (D):  The child has an urosheath or condom with a receptacle attached to collect urine.  Another person cares for the child’s external device or additional incontinence supplies such as briefs, pads, or diapersThis category should be used if the child cannot manage all tasks associated with maintaining an external device independently.

 

  • Indwelling Catheter - Not Self-Care (D):  The child has a hollow cylinder passed through the urethra into the bladder.  Another person cares for the child’s indwelling catheter, additional incontinence supplies such as briefs, pads, or diapers or must perform in and out catheterizations multiple times a dayThis category includes children who self-catheterize, but who need assistance to set-up, clean up, etc. This category should be used if the child cannot complete all components of the tasks associated with an indwelling catheter independently.

 

  • Ostomy - Not Self-Care (D):  The child has a surgical procedure that establishes an external opening into the ureter(s).  Another person cares for the child’s ostomy and may assist with the use, changing, and appropriate disposal of incontinence supplies such as briefs, pads or diapers.  This category should be used if the child cannot manage all components of the tasks associated with ostomy care independently.

 

Rating Criteria for Mobility:

 

Mobility is the extent of the individual's movement outside his or her usual living quarters. Evaluate the individual's ability to walk steadily and his or her level of endurance.

 

Ambulation is the ability to get around indoors (walking) and outdoors (mobility), climb stairs and wheel. Individuals who are confined to a bed or chair must be shown as needing help for all ambulation activities. This is necessary in order to show their level of functioning/dependence in ambulation accurately. Individuals who are confined to a bed or a chair are rated Is Not Performed for all ambulation activities.

 

Walking is the process of moving about indoors on foot or on artificial limbs.

 

Wheeling is the process of moving about by a wheelchair. The wheelchair itself is not considered a mechanical device for this assessment section.

 

Stair Climbing is the process of climbing up and down a flight of stairs from one floor to another. If the individual does not live in a dwelling unit with stairs, ask whether he can climb stairs if necessary.

 

Special Note:  Children from birth through 5 years of age may require supervision for safety and physical assistance.

 

Screening considerations for children, as age appropriate, include:  ability to safely maneuver (ambulate) without assistance, creep up stairs, and kneel without support, and assume standing position; seizure activity; frequent falls; balance; and/or visual concerns. 

 

  • Does Not Need Help (I):    The child, as age appropriate, goes outside of his or her residence on a routine basis.  If the child only goes outside for trips to a medical appointment or for treatments by ambulance, car, or van rate either in the "confined - moves about" or "confined - does not move about" categories. 
  • Children from birth to 6 months of age should be dependent on another person/caregiver for mobility. If the child and caregiver as a unit can achieve mobility and there are no other complex medical needs or equipment, the child is rated as independent.  
  • Children ages 7-12 months of age should be dependent on another person/caregiver for mobility and should be able to maintain a sitting position when placed and able to move self by rolling, crawling, or creeping.  The child requires supervision for safety.  If the child can achieve developmental milestones and there are no other complex medical needs or equipment, the child is rated as independent.   If the child is not able to achieve developmental milestones, then refer to one of the other functional capacities listed below. 
  • Children ages 13-18 months of age (1-year-old) should be dependent on another person/caregiver for mobility and should be able to able to crawl, creep, pull to stand up, and sit alone.  The child requires supervision for safety and intermittent assistance. If the child can achieve the developmental milestones and there are no other complex medical needs or equipment, the child is rated as independent.   If the child is not able to achieve developmental milestones or requires a stander, then refer to one of the other functional capacities listed below.
  • Children ages 19-24 months of age (1 ½ to 2-year-old) should be dependent on another person/caregiver for mobility and be able to walk well, master stair climbing but still require supervision for safety and intermediate assistance. If the child can achieve developmental milestones and there are no other complex medical needs or equipment, the child is rated as independent.   If the child is not able to achieve developmental milestones or requires a stander or other medical assistance such as use a wheelchair, then refer to one of the other functional capacities listed below.
  • Children ages 25 months to 4 years of age should be able to walk well, master physical skills involved in running and jumping but still require supervision for safety and may need intermittent assistance. If the child can achieve developmental milestones and there are no other complex medical needs or equipment, the child is rated as independent.   If the child is not able to achieve developmental milestones or requires a stander or other medical assistance such as use a wheelchair, then refer to one of the other functional capacities listed below.
  • Children from age 5 to 18 years of age should be able to physically perform all essential components of the tasks of mobility safely and without assistance.  If the child is not able to achieve mobility or requires a stander or other medical assistance such as use a wheelchair, then refer to one of the other functional capacities listed below.

 

  • Mechanical Help Only (d):  The child usually needs equipment or a device to go outside independently.  Equipment or device includes splint, special shoes, leg braces, crutches, walkers, wheelchairs, canes, handrails, chairlifts, and special ramps.
  • This category should only be used if the child can utilize equipment or devices independently.

 

  • Human Help Only (D): 

 

Supervision (Verbal Cues, Prompting):  The child, as age appropriate, usually requires assistance from another person who provides supervision, cues, or coaxing in mobility. 

Physical Assistance (Set-up, Hands-On Care):  The child, as age appropriate, usually receives assistance from another person who physically supports or steadies the child to go outside.

 

  • Children from birth to 6 months of age should be dependent on another person/caregiver for mobility and should be rated as independent unless they have a complex medical need or equipment.
  • Children ages 7-12 months of age should be dependent on another person/caregiver for mobility and supervision for safety and should be rated as independent unless they have a complex medical need, equipment, or are unable to reach developmental milestones of maintaining a sitting position when placed or able to move self by rolling, crawling, or creeping. 
  • Children ages 13-18 months of age (1-year-old) should be dependent on another person/caregiver for mobility and supervision for safety and should be rated as independent unless they have a complex medical need, equipment, or are unable to reach developmental milestones of crawling, creeping, pulling to stand up, and sitting alone. 
  • Children ages 19-24 months of age (1 ½ to 2-year-old) should be dependent on another person/caregiver for mobility and supervision for safety including intermittent physical assistance and should be rated as independent unless they have a complex medical need, equipment, or require a stander or other medical assistance such as use a wheelchair or are unable to reach developmental milestones of walking well and mastering stair climbing.
  • Children ages 25 months to 4 years of age should be dependent on another person/caregiver for mobility and supervision for safety including intermittent physical assistance and should be rated as independent unless they have a complex medical need, equipment, or require a stander or other medical assistance such as use a wheelchair or are unable to reach developmental milestones of walking well or mastering physical skills involved in running and jumping.
  • Children from age 5 to 18 years of age should be able to physically perform all essential components of the task of mobility safely and without assistance.  If they are not able to achieve mobility or require a stander or other medical assistance such as use a wheelchair, then this category may be appropriate.

 

  • Mechanical and Human Help (D):  The child, as age appropriate, usually needs equipment or a device and requires assistance of other(s) to go outside as defined above under Mechanical Help and Human Help.
  • Children from birth to 6 months of age should be dependent on another person/caregiver for mobility and should be rated as independent unless they have a complex medical need or equipment.
  • Children ages 7-12 months of age should be dependent on another person/caregiver for mobility and supervision for safety and should be rated as independent unless they have a complex medical need, equipment, or are unable reach developmental milestones of maintaining a sitting position when placed or able to move self by rolling, crawling, or creeping. 
  • Children ages 13-18 months of age (1-year-old) should be dependent on another person/caregiver for mobility and supervision for safety and should be rated as independent unless they have a complex medical need, equipment, or are unable to reach developmental milestones of crawling, creeping, pulling to stand up, and sitting alone. 
  • Children ages 19-24 months of age (1 ½ to 2-year-old) should be dependent on another person/caregiver for mobility and supervision for safety including intermittent physical assistance and should be rated as independent unless they have a complex medical need, equipment, or require a stander or other medical assistance such as use a wheelchair or are unable to reach developmental milestones of walking well and mastering stair climbing.
  • Children ages 25 months to 4 years of age should be dependent on another person/caregiver for mobility and supervision for safety including intermittent physical assistance and should be rated as independent unless they have a complex medical need, equipment, or require a stander or other medical assistance such as use a wheelchair or are unable to reach developmental milestones of walking well or mastering physical skills involved in running and jumping.
  • Children from age 5 to 18 years of age should be able to physically perform all essential components of the task of mobility, safely, and without assistance.  If they are not able to achieve mobility or require a stander or other medical assistance, such as use a wheelchair, then this category may be appropriate.

 

  • Confined - Moves About (D): The child does not customarily go outside of his or her residence, but does go outside of his or her room.
  • Refers only to children confined to residency due to complex medical needs or equipment.

 

  • Confined - Does Not Move About (D):  The child usually stays in his or her room. 
  • Refers only to children confined to bed due to complex medical needs or use of equipment.

 

Rating Criteria for Joint Motion:

 

Joint motion is the child’s ability to move his or her fingers, arms, and legs (active ROM) or, if applicable, the ability of someone else to move the child’s fingers, arms, and legs (passive ROM). 

 

  • Within Normal Limits Or Instability Corrected (I):  means the child’s joints can be moved to functional motion without restriction, or a joint does not maintain functional motion and/or position when pressure or stress is applied, but has been corrected by the use of an appliance or by surgical procedure.

 

 

  • Instability Uncorrected Or Immobile (D): means a joint does not maintain functional motion and/or position when pressure or stress is applied and the disorder has not been surgically corrected or an appliance is not used, or there is total restriction in the movement of a joint (e.g., contractures, which are common in individuals who have had strokes).   

 

 

Rating Criteria for Medication Administration:

 

Medication Administration refers to the person(s) who administers medications such as the child and caregiver as a unit, the child as age appropriate, or if the child is being referred elsewhere, the person(s) who will administer medications following referral. 

 

  • Without Assistance or No Medications (I):  means the child and caregiver as a unit or the child independently administers their own medication or does not take any medications. 

 

  • Administered/Monitored by Lay Person(s) (D):  The child and caregiver as a unit or the child needs additional assistance of a person without pharmacology training to either administer or monitor medications.  This includes medication aides that may be-certified but not licensed or programmed medication dispensers.  If meds are given by lay and professional staff, rate at the higher level.

 

  • Administered/Monitored by Professional Nursing Staff (D):  The child needs licensed or professional health personnel to administer or monitor some or all of the medications.  If meds are given by lay and professional staff, rate at the higher level.

 

Rating Criteria for Behavior Pattern and Orientation:

 

Behavior Pattern is the manner of conducting oneself within one's environment without placing oneself at risk.

 

Orientation is the awareness of an individual within his or her environment in relation to time, place, and person.  It can also mean the recognition of danger.

 

See crosswalk at the end of this section and as a quick reference guide, Attachment A.

 

 

Screening considerations for children, as age appropriate, include:  assistance to engage in safe actions and interactions; refrain from unsafe actions and interactions; exhibits disruptive or dangerous behavior such as: verbal and physical abuse to self or others; wandering; removing or destroying property; acting in a sexually aggressive manner; reported neurological impairment; hyper/hypo sensitivity to external stimulus; constant vocalizations/perseveration; impaired safety skills; engages in smearing behavior; sleep deprivation; reported cognitive impairment; lack of awareness; unable to respond to cues; unable to communicate basic needs and wants; disorientation/disassociation; unable to follow directions; unable to process information or social cues; and unable to recall personal information. If the child exhibits any of these, rate accordingly as developmentally appropriate.

BEHAVIOR PATTERN (Children PAS)

  • Appropriate (I):  The child's behavior pattern is suitable or fitting to the environment and age of the child.  Appropriate behavior is of the type that adjusts to accommodate expectations in different environments and social circumstances.  Behavior pattern does not refer to personality characteristics such as "selfish," "impatient," or "demanding," but is based on direct observations of the individual's actions. If the behavior is not appropriate, then refer to one of the other functional capacities listed below.
  • Children from birth to 5 months are developmentally expected to respond to sounds by startling; fixate on human’s face; respond to caregivers face and voice; move extremities; and smile responsively.  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.
  • Children from 6-12 months are developmentally expected to respond to sounds; own name; string vowels together when babbling (ah, eh, oh); make sounds to show joy and displeasure; play with others; respond to emotions; show anxiety with strangers; and like to look at self in mirror. If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.
  • Children from 13-36 months are developmentally expected to respond to simple spoken requests, use simple gestures like shaking head no or waving bye; say mama or dada or uh-oh or other single words; point to show someone what they want or to identify; know names of familiar people and things; demonstrate shyness or nervousness with strangers; cry when caregiver leaves; show fear in some situations; has favorite things and people; hands things to others as play; plays with doll; copies others; gets excited with other children; and may show defiant behavior. If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.    
  • Children from 37 months to 4 years of age are developmentally expected to effectively share information and wants and needs; use simple words, phrases, or short sentences; be able to ask for at least 10 things using appropriate names; understand instructions; and demonstrate the ability to initiate conversation; identify self and significant others; recognize person, places, events, and objects in their community.  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.   
  • Children from 5-18 years of age are developmentally expected to identify self, place of residence, and significant others.  For age 6 years and older, engages others in a socially appropriate manner and recognizes and appropriately responds to dangerous situations that might put health and safety at risk or lead to exploitation (this includes wandering and flight behavior).  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.  

 

  • Inappropriate Wandering, Passive, or Other:

Wandering/Passive < weekly = (I);

Wandering/Passive Weekly or More = (d):

The child's usual behavior is manifested in a way that does not present major management problems.  Wandering is characterized by physically moving about aimlessly or mentally being non-focused.  Passive behavior is characterized by a lack of awareness or interest in personal matters and/or in activities taking place in close proximity.  Other characterizations of behavior such as impaired judgment, regressive behavior, agitation, or hallucinations that is not disruptive are included in this category.   If the behavior is not appropriate or the child has a risk as stated above under considerations, then this category may be appropriate.    

  • Children from birth to 5 years of age should be dependent on another person/caregiver for mobility and supervision for safety and should be rated as independent unless they have a complex medical condition.
  • Children from 5-18 years of age are developmentally expected to identify self, place of residence, and significant others.  For age 6 years and older, engages others in a socially appropriate manner and recognizes and appropriately responds to dangerous situations that might put health and safety at risk or lead to exploitation (this includes wandering and flight behavior).  If the child cannot meet developmental milestones, then this category may be appropriate.

 

  • Inappropriate Abusive, Aggressive, or Disruptive:

Abusive/Aggressive/Disruptive < Weekly = (D);

Abusive/Aggressive/Disruptive Weekly or More = (D):

The child's behavior is manifested by acts detrimental to the life, comfort, safety, and/or property of the child and/or others.  Agitations, hallucinations, or assaultive behavior that is detrimental are included in this category and specified in the space provided. If the behavior is described as above or the child has a risk as stated under considerations, then this category may be appropriate.        

  • Children birth to 12 months should be dependent on another person/caregiver for supervision for safety and this category does not apply unless they have a complex medical condition.
  • Children 13 months-18 years of age; this category may be appropriate.

 

  • Comatose refers to the semi-conscious or comatose (unconscious) state.  (D)

ORIENTATION (Children PAS)

  • Oriented (I):  The individual has no apparent problems with orientation and is aware of who he or she is, where he or she, the day of the week, the month, and people around him or her.
  • Children from birth to 5 months are developmentally expected to respond to sounds by startling; fixate on human’s face; respond to caregivers face and voice; move extremities; and smile responsively.  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.
  • Children from 6-12 months are developmentally expected to respond to sounds; own name; string vowels together when babbling (ah, eh, oh); make sounds to show joy and displeasure; play with others; respond to emotions; show anxiety with strangers; and like to look at self in mirror. If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.
  • Children from 13-36 months are developmentally expected to respond to simple spoken requests, use simple gestures like shaking head no or waving bye; say mama or dada or uh-oh or other single words; point to show someone what they want or to identify; know names of familiar people and things; demonstrate shyness or nervousness with strangers; cry when caregiver leaves; show fear in some situations; has favorite things and people; hands things to others as play; plays with doll; copies others; gets excited with other children; and may show defiant behavior. If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.    
  • Children from 37 months to 4 years of age are developmentally expected to effectively share information and wants and needs; use simple words, phrases, or short sentences; be able to ask for at least 10 things using appropriate names; understand instructions; and demonstrate the ability to initiate conversation; identify self and significant others; recognize person, places, events, and objects in their community.  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.   
  • Children from 5-18 years of age are developmentally expected to identify self, place of residence, and significant others.  For age 6 years and older, engages others in a socially appropriate manner and recognizes and appropriately responds to dangerous situations that might put health and safety at risk or lead to exploitation (this includes wandering and flight behavior).  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.  

 

  • Disoriented-Some Spheres, Some of the Time (d):  The individual sometimes has problems with one or two of the three cognitive spheres of person, place, or time.  Some of the Time means there are alternating periods of awareness-unawareness. 
  • Children from birth to 5 months are developmentally expected to respond to sounds by startling; fixate on human’s face; respond to caregivers face and voice; move extremities; and smile responsively.  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.
  • Children from 6-12 months are developmentally expected to respond to sounds; own name; string vowels together when babbling (ah, eh, oh); make sounds to show joy and displeasure; play with others; respond to emotions; show anxiety with strangers; and like to look at self in mirror. If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.
  • Children from 13-36 months are developmentally expected to respond to simple spoken requests, use simple gestures like shaking head no or waving bye; say mama or dada or uh-oh or other single words; point to show someone what they want or to identify; know names of familiar people and things; demonstrate shyness or nervousness with strangers; cry when caregiver leaves; show fear in some situations; has favorite things and people; hands things to others as play; plays with doll; copies others; gets excited with other children; and may show defiant behavior. If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.    
  • Children from 37 months to 4 years of age are developmentally expected to effectively share information and wants and needs; use simple words, phrases, or short sentences; be able to ask for at least 10 things using appropriate names; understand instructions; and demonstrate the ability to initiate conversation; identify self and significant others; recognize person, places, events, and objects in their community.  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.   
  • Children from 5-18 years of age are developmentally expected to identify self, place of residence, and significant others.  For age 6 years and older, engages others in a socially appropriate manner and recognizes and appropriately responds to dangerous situations that might put health and safety at risk or lead to exploitation (this includes wandering and flight behavior).  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.  

 

  • Disoriented-Some Spheres, All of the Time (d):  The individual is disoriented in one or two of the three cognitive spheres of person, place, and time.  All of the time means this is the individual’s usual state.
  • Children from birth to 5 months are developmentally expected to respond to sounds by startling; fixate on human’s face; respond to caregivers face and voice; move extremities; and smile responsively.  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.
  • Children from 6-12 months are developmentally expected to respond to sounds; own name; string vowels together when babbling (ah, eh, oh); make sounds to show joy and displeasure; play with others; respond to emotions; show anxiety with strangers; and like to look at self in mirror. If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.
  • Children from 13-36 months are developmentally expected to respond to simple spoken requests, use simple gestures like shaking head no or waving bye; say mama or dada or uh-oh or other single words; point to show someone what they want or to identify; know names of familiar people and things; demonstrate shyness or nervousness with strangers; cry when caregiver leaves; show fear in some situations; has favorite things and people; hands things to others as play; plays with doll; copies others; gets excited with other children; and may show defiant behavior. If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.    
  • Children from 37 months to 4 years of age are developmentally expected to effectively share information and wants and needs; use simple words, phrases, or short sentences; be able to ask for at least 10 things using appropriate names; understand instructions; and demonstrate the ability to initiate conversation; identify self and significant others; recognize person, places, events, and objects in their community.  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.   
  • Children from 5-18 years of age are developmentally expected to identify self, place of residence, and significant others.  For age 6 years and older, engages others in a socially appropriate manner and recognizes and appropriately responds to dangerous situations that might put health and safety at risk or lead to exploitation (this includes wandering and flight behavior).  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.  

 

  • Disoriented-All Spheres, Some of the Time (D):  The individual is disoriented to person, place, and time periodically, but not always.
  • Children from birth to 5 months are developmentally expected to respond to sounds by startling; fixate on human’s face; respond to caregivers face and voice; move extremities; and smile responsively.  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.
  • Children from 6-12 months are developmentally expected to respond to sounds; own name; string vowels together when babbling (ah, eh, oh); make sounds to show joy and displeasure; play with others; respond to emotions; show anxiety with strangers; and like to look at self in mirror. If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.
  • Children from 13-36 months are developmentally expected to respond to simple spoken requests, use simple gestures like shaking head no or waving bye; say mama or dada or uh-oh or other single words; point to show someone what they want or to identify; know names of familiar people and things; demonstrate shyness or nervousness with strangers; cry when caregiver leaves; show fear in some situations; has favorite things and people; hands things to others as play; plays with doll; copies others; gets excited with other children; and may show defiant behavior. If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.    
  • Children from 37 months to 4 years of age are developmentally expected to effectively share information and wants and needs; use simple words, phrases, or short sentences; be able to ask for at least 10 things using appropriate names; understand instructions; and demonstrate the ability to initiate conversation; identify self and significant others; recognize person, places, events, and objects in their community.  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.   
  • Children from 5-18 years of age are developmentally expected to identify self, place of residence, and significant others.  For age 6 years and older, engages others in a socially appropriate manner and recognizes and appropriately responds to dangerous situations that might put health and safety at risk or lead to exploitation (this includes wandering and flight behavior).  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.  

 

  • Disoriented-All Spheres, All of the Time (D):  The individual is always disoriented to person, place, and time.
  • Children from birth to 5 months are developmentally expected to respond to sounds by startling; fixate on human’s face; respond to caregivers face and voice; move extremities; and smile responsively.  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.
  • Children from 6-12 months are developmentally expected to respond to sounds; own name; string vowels together when babbling (ah, eh, oh); make sounds to show joy and displeasure; play with others; respond to emotions; show anxiety with strangers; and like to look at self in mirror. If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.
  • Children from 13-36 months are developmentally expected to respond to simple spoken requests, use simple gestures like shaking head no or waving bye; say mama or dada or uh-oh or other single words; point to show someone what they want or to identify; know names of familiar people and things; demonstrate shyness or nervousness with strangers; cry when caregiver leaves; show fear in some situations; has favorite things and people; hands things to others as play; plays with doll; copies others; gets excited with other children; and may show defiant behavior. If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.    
  • Children from 37 months to 4 years of age are developmentally expected to effectively share information and wants and needs; use simple words, phrases, or short sentences; be able to ask for at least 10 things using appropriate names; understand instructions; and demonstrate the ability to initiate conversation; identify self and significant others; recognize person, places, events, and objects in their community.  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.   
  • Children from 5-18 years of age are developmentally expected to identify self, place of residence, and significant others.  For age 6 years and older, engages others in a socially appropriate manner and recognizes and appropriately responds to dangerous situations that might put health and safety at risk or lead to exploitation (this includes wandering and flight behavior).  If the child can meet developmental milestones, rate as independent.  If they are not able to achieve developmental milestones, then rate accordingly.  

 

  • Comatose (D):  The individual is in a semi-comatose or unconscious state or is otherwise non-communicative.

 

 

Behavior and Orientation are considered as a combination for service authorization.  Please see the chart below that provides the combinations that determine whether or not an individual is independent (I), semi-dependent (d), or dependent (D) in both behavior and orientation for the purposes of Screening for Medicaid LTSS. 

 

Attachment A provides the following crosswalk as a “pull out” tool which can be used in determining eligibility.

 

ORIENTATION PATTERN

  

BEHAVIOR PATTERN

Appropriate

Wandering/

Passive Less Than Weekly

Wandering/

Passive Weekly or More

Abusive/Aggressive/

Disruptive Less Than Weekly

Abusive/ Aggressive/Disruptive Weekly or More

Oriented

I

I

I

d

d

Disoriented: Some spheres Some of the time

I

I

d

d

D

Disoriented: Some spheres All of the time

I

I

d

d

D

Disoriented: All spheres Some of the time

d

d

d

D

D

Disoriented: All spheres All of the time

d

d

d

D

D

Comatose

D

D

D

D

D

 


Reminder:  An individual must meet all criteria to meet NF LOC, i.e., the individual has limited functional capacity, medical or nursing needs, and is at risk of NF placement within 30 days without services.

 

Attachment B of this manual provides a worksheet for summarizing the results of the LTSS Screening and determining functional, medical or nursing need, and at-risk status of the individual.

 

Target Population & General Criteria for HCBS (PAS)

LTSS Screeners are responsible for providing general information regarding Medicaid HCBS as well as non-Medicaid service and support options. As such, LTSS Screeners should be knowledgeable about available community services and supports and have a current list available, with contact information, for individuals who are screened.

 

NOTE: The following information regarding the CCC Plus Waiver and PACE are program snapshots. For additional details, please refer to the individual program provider manuals found on the Virginia Medicaid portal found under provider resources at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/Home/homepage/.

 

Virginia has two HCBS programs that require a Medicaid LTSS Screening as described in this manual. These programs are:

 

  • Program of All-Inclusive Care for the Elderly (PACE); and
  • Commonwealth Coordinated Care Plus (CCC Plus) Waiver

Program of the All-Inclusive Care for the Elderly (PACE)

 

PACE is a program that serves individuals who meet the level of care for NFs.  It is an alternative to long term NF placement. PACE services are all inclusive and highly coordinated, focusing on improving the individual's whole life. Services include adult day care, acute care, dental services, care by a physician, transportation, pharmaceuticals, home health, all rehabilitation services and any other services that the Interdisciplinary Team agrees is needed by the individual.

 

PACE is a capitated rate program jointly funded by Medicare and Medicaid. 

 

The general requirements for PACE are:

 

  1. Be fifty-five (55) years of age or older; and
  2. Reside in a PACE program’s service area; and
  3. Meet NF LOC; and
  4. Have a safe plan of care developed allowing the individual to live in the community; and
  5. Agree to the terms and conditions of participation in the PACE program; and,
  6. Have an income equal to or less than 300% of the current Social Security Income.

 

NOTE:  The PACE program requires LTSS Screenings for ALL individuals entering the program regardless of payment source.  The Screening teams must complete the LTSS Screening for individuals who are anticipating accessing PACE services, even if the individual will access those services under a private pay status.  DMAS will reimburse the LTSS Screening team for these Screenings.  For all individuals screened for PACE, the LTSS Screening Team must send a copy of the successfully processed Screening packet to the selected PACE site.

 

Services available through PACE are all-inclusive and include all acute, medical, dental, long-term services and supports, etc.  For this reason, a list is not included here. 

 

Commonwealth Coordinated Care Plus (CCC Plus) Waiver

Individuals utilizing this waiver may be enrolled in the Commonwealth Coordinated Care Plus (CCC Plus) Program (Virginia’s Medicaid managed long-term care services and supports program) or be Fee for Service (FFS). 

 

To participate in the CCC Plus Waiver, individuals must meet all of the following general requirements:

 

  1. Meet the NF LOC criteria, has medical or nursing needs, and is at risk for NF or hospital placement within 30 days in the absence of HCBS;
  2. Has been determined financially eligible for Medicaid coverage;
  3. Is not a resident of a NF or assisted living facility (ALF) that serves four or more individuals;
  4. Has insufficient community resources or no other community resources available to meet their needs;
  5. Has a safe plan of care developed allowing them to live in the community; and
  6. Has a viable back-up plan for available caregivers.

 

Services available through the CCC Plus Waiver include:

 

  • Adult Day Health Care
    • Assistive Technology (AT). This is not a stand-alone service and must be authorized in addition to one of the other services available in this waiver.
    • Environmental Modification (EM). This is not a stand-alone service and must be authorized in addition to one of the other services available in this waiver.
    • Personal Care Services (Agency and Consumer-Directed options)
    • Personal Emergency Response System (PERS): Installation and may or may not include monthly monitoring. This is not a stand-alone service and must be authorized in addition to one of the other services available in this waiver.
  • Medication Monitoring (can only be received in conjunction with PERS)
    • Private Duty Nursing (PDN)
    • Respite Services (Agency and Consumer-Directed options)
    • Service Facilitation (for Consumer Direction)
  • Transition Services

 

Individuals living with MI, ID or other RC, including autism, individuals in therapeutic foster care or individuals living with behavioral health conditions may qualify for the CCC Plus Waiver; however, all individuals utilizing the CCC Plus Waiver must meet the CCC Plus Waiver criteria i.e. functional need, medical or nursing need, and risk for institutionalization within 30 days. Eligible individuals may be enrolled in the CCC Plus Waiver, while also being on a wait list for one of the DD waivers. Individuals seeking enrollment in a DD waiver must meet that waiver’s criteria and individuals already receiving a DD waiver who wish to change and receive CCC Plus Waiver services, must have a LTSS Screening and meet CCC Plus Waiver criteria.

 

Private Duty Nursing (PDN) Services Offered through the CCC Plus Waiver or EPSDT

 

Adults requiring PDN and children requiring Early and Periodic Screening, Diagnostic and Treatment (EPSDT)  PDN services may be screened for the CCC Plus Waiver the same as other individuals; however, these individuals require more substantial medical nursing interventions. CCC Plus Waiver PDN services shall be covered only for Medicaid-eligible individuals who have been determined eligible for CCC Plus Waiver services and who also require the level of care provided in either a specialized care NF, or long-stay hospital, or are determined to have needs with can only be addressed by a private duty nurse and who meet criteria assessment evaluated on the DMAS-108 (adults) or DMAS-109 (children). PDN services shall be the critical services necessary to delay or avoid the individual's placement in an appropriate facility. Eligibility for the CCC Plus Waiver based on PDN services needs is determined by using the DMAS-108 (for adults) and the DMAS-109 (for children) forms in conjunction with the Medicaid LTSS Screening forms. Medical and nursing needs are documented on the DMAS-108 or DMAS-109. 

 

The DMAS 109 form should only be submitted for children who qualify for at least 50 points or more on the form (ventilator, trach or combinations of conditions as direction on the DMAS-109 form). Completing the form for children who meet the DMAS-109, 50 point criteria, allows them to be enrolled in the CCC Plus Waiver as a medically complex individual even though their PDN must be provided through the EPSDT program.  Please review directions specified on the DMAS-109 form.

 

EPDST provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services.  More information about Virginia’s EDPST Program can be found at http://www.dmas.virginia.gov/#/maternalepsdt.

 

For LTSS screening teams, eMLS will allow opening DMAStheDMAS-108 and DMAS-109 forms when PDN service is selected on the DMAS-96 Authorization form page.  Final eligibility is determined using the age appropriate PDN referral form, in addition to the UAI, DMAS-96 and DMAS-97. 

 Consumer-Directed or Agency-Direct Personal Care

Agency-directed care is where services are coordinated and received through an agency who is responsible for hiring and training its employees.  Consumer-directed care is where the individual (or an appointee) is the employer of the persons providing services.  Individuals may receive personal care, adult day health care, respite (skilled and non-skilled), PDN and Personal Emergency Response System (PERS) through an agency-directed model of care. Individuals may also receive personal care and non-skilled respite through a consumer-directed model of care. The choice of the model of care is made freely by the individual or their representative, if the individual is not able to make a choice.

Movement Between NF, CCC Plus Waiver and PACE After Initial Screening for Medicaid-Funded LTSS

Individuals meeting NF LOC criteria are able to choose their services and transition among certain LTSS settings (NF, CCC Plus Waiver and PACE) after the initial Medicaid LTSS Screening and service enrollment/authorization occurs, provided all the requirements are met for the newly selected setting or program. Examples of additional criteria that must be met from one services program to another include:  age requirement for PACE, and the completion of a Level I Screening and if needed, a Level II evaluation and determination for MI, ID and RC, for all admissions to a Medicaid-certified NF. Movement provides choice to the individual and enables the individual to more freely move between NF and CCC Plus Waiver, PACE or between NFs.

 

After an initial Medicaid LTSS Screening is conducted and successfully processed in eMLS, enrollment in services shall occur as soon as possible after LTSS Screening but no later than one year from date of the LTSS Screening.  If enrollment does not occur within one (1) year a new LTSS Screening is required. 

 

LTSS annual LOC review will be monitored using established processes for the CCC Plus Waiver (as found in the CCC Plus Waiver Manual) and the Minimum Data Set (MDS) in NFs. PACE sites will follow their usual process for monitoring annual LOC. A new LTSS screening is not needed nor is an updated Screening required for persons enrolled for Medicaid LTSS unless an individual is terminated from enrollment for services.

 

When there is a transition of services from one provider to another, it is up to the FFS LTSS provider, individual's CCC Plus health plan or PACE site to ensure that all documentation including LTSS Screening packet is forwarded to a new provider in order for an appropriate and safe plan of care to be developed. If the existing provider does not have a copy of the LTSS Screening packet, any of the providers serving the individual or the original LTSS Screening team should assist in providing a LTSS Screening packet.  Copies of the LTSS Screening packet can be printed from eMLS.

 

If an individual is unenrolled from Medicaid and/or Medicaid LTSS enrollment is terminated and the individual wishes to restart/reinitiate LTSS, a new Screening is required.  In this situation, the initiation of services is considered a new application for LTSS.

Preauthorizations and Referrals (PAS)

DMAS Authority for Authorization of Medicaid Payment

 

The Screening teams have the responsibility to determine if the individual meets the initial required NF LOC.  The DMAS eMLS system does not determine the LOC.  The LTSS Screening team determines eligibility and by selecting a category of service on the DMAS-96 Authorization Form (CCC Plus Waiver, PDN services, PACE or NF), the Screener is documenting the authorization determination.  This determination is needed for Medicaid reimbursement of LTSS.  Any information that is needed to support the Screening team’s LOC decision must be documented on the last page (narrative section) of the DMAS-P98 (UAI-B) in  eMLS.  FFS LTSS providers are responsible for developing the plan of care and requesting authorization for services.  FFS authorizations are submitted to the DMAS-designated service authorization contractor. CCC Plus health plans will manage these processes for individuals enrolled in the CCC Plus managed care program.

 

In those cases where the individual has been referred for a Level II evaluation for SMI, ID/RC, the responsibility and authority for the authorization of services is shared with the state DBHDS and contracted evaluation team.  The Level II authorization must occur prior to service initiation for NF services. The LTSS Screening teams must document the findings of the Level II in  eMLS.

 

NFs will not be reimbursed by DMAS for NF placement or services until a LTSS Screening has been completed and successfully processed in  eMLS (as described in this manual) and the individual is determined to meet the initial required LOC criteria for LTSS (except for special circumstances allowing NF admission without LTSS Screening).  It is the NF’s responsibility not to accept an individual for LTSS nor submit a LOC change from skilled services (including rehabilitation services) to LTSS before the completion of a Screening.

 

Freedom of Choice

 

The Screening team shall inform the individual of the feasible alternatives available for LTSS and allow the individual to choose either institutional or HCBS programs (Title 42: Subpart H§441.353(d).)    Regardless of the LTSS services authorization, the individual shall be given choice of settings (HCBS or NF) and of services and providers.  The Screening team must document the individual’s choices on the Individual Choice-Institutional Care or Waiver Services Form (DMAS-97). This includes documenting that an individual has chosen to decline services, if that is the case. 

 

All of the following information, which is included on the DMAS-97, shall be discussed with the individual or his or her representative during the Screening, and documented on the DMAS-97:

 

  • The findings and results of the individual’s evaluation and needs;

 

  • A choice between NF, CCC Plus Waiver, or PACE;

 

  • For individuals selecting NF, the individual’s understanding that when there is a suspected or known diagnosis of a MI, ID or RC, a Level II Screening is required to determine if additional services are necessary;

 

  • The individual’s right to a fair hearing and the appeal process;

 

  • The individual’s right to choose provider(s).When an individual is participating in the CCC Plus program the Screener will inform the individual that the health plan will provide a list of available providers enrolled with the plan; when an individual is FFS the Screener will provide a list of available community providers;

 

  • The individual’s right to choice of service(s);  

 

  • The individual’s potential to have a patient pay amount, based on his or her income regardless of the amount of NF/HCBS programs;  

 

  • The individual understands that, by using the Consumer-Directed (CD) Option of service delivery, he or she bears the responsibilities associated with employing his or her own personal care attendants (NOTE:  DMAS is not the employer for CD personal care attendants providing personal care, companion services, or respite services); and

 

  • The individual’s (or representative’s) consent to exchange information with DMAS by signing and dating the DMAS-97 form.  This consent will remain in effect until revoked by the individual (or representative) in writing.

 

The Screening team must document that the individual was provided a choice on the DMAS-97 form in eMLS and have the individual sign a copy for file records.   If a provider is chosen, this selection should be noted on the DMAS-97 form.    If services are declined that should also be noted.

 

The Screening team must also inform the individual and/or the representative of all of the following requirements:

 

  1. The authorization for Medicaid-funded LTSS does not mean that the individual will become financially Medicaid-eligible;

 

  1. Financial eligibility for Medicaid coverage must be determined by a benefits (eligibility) worker at the LDSS and that may include responsibility for a patient-pay amount; and

 

  1. Medicaid shall not reimburse for services unless the individual has been determined to be financially Medicaid-eligible and meets the LOC criteria for service authorization.

 

The Screening team will send a letter documenting its decision to the selected provider, health plan health plan and individual. The approval and denial sample letters have been revised and are located for screener access on the Medicaid Web Portal under Provider Services/Provider Forms Search at:  https://www.virginiamedicaid.dmas.virginia.gov/wps/portal.  Under Category, use the drop-down menu and click on Pre-Admission Screening to access the sample letters, DMAS-P238, Approval Letter and DMAS-P239, Denial Letter. 

 

Additional Non-Medicaid Covered Services

 

An individual shall be notified of non-Medicaid community services that can provide support based on their needs.  The individual or family may choose the additional services from any source, including a community-based agency or be determined eligible or possibly eligible for other programs by local human services agencies.

Referrals for NF, CCC Plus Waiver and PACE

 

The LTSS Screening team must consider the individual’s health, safety, and welfare as well as the individual’s choice of provider and setting when considering HCBS such as the CCC Plus Waiver or PACE.  If the individual already has an APS or CPS worker assigned through the local DSS and it is known by the LTSS Screening team or contact can be accessed, this individual should be consulted.  In order to authorize HCBS, the individual must meet all of the criteria for the specific HCBS program prior to authorization. CCC Plus Health Plan Care Coordinators will work with plan members to assure health, safety, and welfare for the member while respecting the individual’s choice of provider and setting for services.  

 

HCBS should first be discussed with the individual; however, NF services cancan be authorized with documentation addressing why HCBS cannot be authorized.  This action can allow for temporary placement in a NF setting until a safe plan of care can be developed for HCBS.

 

For individuals choosing a NF, LTSS Screeners must ensure the completion of the DMAS-95 (screening for MI, ID/RC) and make appropriate referral for a Level II evaluation and determination if MI/ID/RC are suspected.  Both the MI/ID/RC screening (Level I) and evaluation (Level II) process must be completed prior to NF admission.

 

The Screening team must document the individual’s choices on the DMAS-97 in eMLS.

 

FFS and CCC Plus Excluded Population Process

For individuals that are FFS or in a CCC Plus excluded population or program, the LTSS Screening team must inform the individual of Medicaid policies and alternatives to NF placement (CCC Plus Waiver and PACE). If the individual being screened is FFS, the LTSS Screening team must offer a written list of Medicaid-enrolled provider agencies and/or CD services facilitators in their area, and PACE providers (if applicable).  The individual’s choice of provider should be documented.  A current list of DMAS enrolled CCC Plus Waiver providers can be found at:

https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/SearchForProviders.  Under Provider Type select Case Management – Waiver and Service Facilitation (for consumer-directed services), Personal Care (for agency-directed services), or PDN.  For PACE choose PACE Provider.

 

 

Per the individual’s choice, the Screening team will forward a complete Medicaid LTSS Screening Packet to the selected provider.  The provider (CD Services Facilitator or Agency) will manage the LTSS enrollment process.

 

CCC Plus Program Process

If the individual is enrolled in a health plan CCC Plus health, then the LTSS Screening team will forward all screening documentation to the CCC Plus health plan fax number (listed later in this Chapter) for follow-up with the individual by the individual’s care coordinator.  The health plan will manage the LTSS enrollment process.

 

The LTSS Screener should provide general information regarding NF, CCC Plus Waiver, and if applicable, PACE services, as well as inform the individual that the CCC Plus care coordinator will provide a list of available network choices to the individual. Individuals may also visit the following DMAS webpage to investigate providers who are enrolled with their health plan:  https://www.dmas.virginia.gov/for-members/find-a-provider/

 

eMLS

 

PACE Program Process:

Individuals interested in PACE should be provided contact information for the PACE program serving the locality (if PACE is available).  Individuals should be directed to discuss their interest with the PACE staff.   If the individual chooses PACE services, this choice should be noted on the authorization form.  The local PACE program will notify DMAS regarding the potential enrollee and manage the PACE enrollment process for the individual.

Documentation Requirements (PAS)

Distribution of Screening Forms

The LTSS Screening team sends the following forms as outlined below.  No LTSS Screening packet should be distributed until it has “Successfully Processed” as noted in  eMLS. Once a LTSS Screening is submitted via  eMLS, the LTSS Screener is responsible for returning to the  eMLS portal after 24 hours to confirm the forms were Successfully Processed and print copies of the packet as needed.  No handwritten forms/screening packets should be forwarded to a provider or individual.

 

Please note that it should be standard practice for LTSS Screening entities to provide copies of the LTSS Screening packet to the individual or the authorized representative. LTSS Screening packets should also be provided to newly chosen providers if all information security (PHI) guidelines are followed and it is within the record and retention timeframes for the Screening entity.

 

Medicaid LTSS Screening, Form Distribution

 

CCC Plus Member

Forms Sent to Health Plan

FFS Members

Forms Sent to Provider

PACE Admissions

Forms Sent to Provider

NF Admission

 

 Full Screening Package sent to Admitting NF

CCC Plus Waiver

NF Admission

 

Full Screening Package sent to Admitting NF

CCC Plus Waiver

 

DMAS-P98

DMAS-P98

DMAS-P98

DMAS-P98

DMAS-P98

DMAS-95

  • Level I
  • Level II (if appropriate)

 

DMAS-95

  • Level I
  • Level II (if appropriate

 

 

DMAS-96

DMAS-96

DMAS-96

 

DMAS-96

DMAS-96

DMAS-97

DMAS-97

 

DMAS-97

 

DMAS-97

 

DMAS-97

 

 

DMAS-108 (as appropriate)

 

DMAS-108 (as appropriate)

 

 

DMAS-109 (as appropriate)

 

DMAS-109 (as appropriate)

 

*A copy of the DMAS-96 is always forwarded to the benefits unit of the LDSS.

 

** The original signed copy of the DMAS-97 should be maintained with the individual’s official record and transferred to the new provider if the individual transitions to a new service provider.  All other providers may retain a printed copy of the DMAS-97 noting names of original signers.

 

*** The individual screened for LTSS or the representative must receive a notification letter providing appeal rights and a copy of the full LTSS Screening packet.  Please note that the notification letter is not to be used for authorization of services.  Only a LTSS Screening packet which includes the DMAS-96 Authorization for LTSS Form can be used to confirm authorization.

 

Screeners will need to retain copies of the Screening packet per retention policy cited in this manual or upon request retrieve LTSS Screening packets from eMLS.

 

For Medicaid Members who are enrolled with a CCC Plus program health plan, Screeners will need to determine whether individuals are currently CCC Plus members, and if so, forward the completed Screening packet to the health plan for use by the individual’s assigned care coordinator.  Contact and FAX numbers are listed below. 

 

 

 

 

CCC Plus Health Plan

FAX Number for Screening Documents

Care Coordination Phone Number

Aetna Better Health of Virginia

844-459-6680

855-652-8249 

Press #1 and ask for Case Management

Anthem HealthKeepers Plus

855-471-7937

855-323-4687 (Option 4)

TTY 711

Magellan Complete Care of Virginia

866-210-1523

800-424-4524

 

Optima Health Community Care

844-552-7508

866-546-7924 or

757-552-8398

United Healthcare Community Plan

 

855-770-7088

Providers

 877-843-4366

Members

1-866-622-7982

Virginia Premier Health Plan

800800-846-4254

877-719-7358

press option 1, then 3 

 

For individuals enrolled in the CCC Plus program, the health plan is responsible for submitting the DMAS-225 to the LDSS benefits program (eligibility section) once services are initiated for the individual.

 

For FFS for NF, CCC Plus Waiver and PACE, the direct service provider is responsible for notifying the LDSS eligibility section via a DMAS-225 that services have been initiated for the individual.

 

Electronic Medicaid LTSS Screening System ( eMLS- electronic screening system for LTSS)

 

LTSS Screening teams shall enter the Screening information directly into the  eMLS –the electronic screening system for LTSS...  eMLS is required for recording the results of LTSS Screenings, maintaining records, and noting authorization or non-authorization for the CCC Plus Waiver, PACE or LTSS provided in a NF.  LTSS Screeners should note that the system is not used for maintaining other types of screenings using the UAI form, such as assessments for Assisted Living Facilities (ALFs) nor does the system automatically enroll individuals into the aforementioned programs/services.

 

  1. On-line Screening forms identify all required data elements for successful submission..

 

  1. Submissions are imported directly into the DMAS’ Virginia Medicaid Management Information System (VAMMIS) each evening for processing and review..

 

  1. The LTSS Screener submitting the LTSS Screening must log into  eMLS to verify the status of the LTSS Screening the day following the LTSS Screening submission.  Status tracking may indicate ‘successfully processed,” ‘denied’, ‘ed’ or ‘incomplete’. When a LTSS Screening indicates “Submitted for Processing” it means the LTSS Screening has not yet been processed by the computer systems.  If LTSS Screeners find this message more than 24 hours after submission, the LTSS Screener should contact ScreeningAssistance@dmas.virginia.gov ..

 

  1. If additional information or corrections are needed, each item can be viewed by the LTSS Screener who entered the data and submitted the forms for the screening. A description of the information or correction needed will appear directly below each data element in  eMLS..

 

  1. Default social security numbers (SSN) should not be used except under circumstances when a child has not yet been issues a SSN.   The DMAS approved default social security number sequence is 000-MM-DDYY using the individual’s Date of Birth (no other sequence is allowed-000s, 222s,333s, etc.); if having trouble or receiving denial codes contact: screeningassistance@dmas.virginia.gov. Any and all LTSS Screenings utilizing a default SSN must be revises once a SSN has been issued. LTSS Screeners should contact screeningassistance@dmas.virginia.gov  for assistance with this process.
  2. All LTSS Screenings can be printed from eMLS

 

  1. An indication of successfully submitted, submitted for processing, incomplete, pended or denied only indicates the status of submitted data.   eMLS has been built to assist the LTSS Screener in assuring all required information is entered into the system, it does automatically complete the Medicaid LTSS authorization form .  .;

 

  1. Upon successful completion of entering the LTSS Screening data, VAMMIS will generate a claim for payment of the LTSS Screening to the hospital or local health department associated with the individual’s screening. And

 

  1. The claim payment will be paid for specific social security and Medicaid numbers; thus, enabling the individual entering the data to track the claim and subsequent payment.

 

Detailed information is available regarding accessing the DMAS Provider Web Portal ( eMLS).

 

  1. Screening eMLS User Guide, Tutorial and Frequently asked Questions (FAQs) are available on the Virginia Medicaid Provider Web Portal located at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/PreAdmission

 

  1. Questions may also be submitted through the DMAS screening assistance email address at: ScreeningAssistance@dmas.virginia.gov

 

 

Notification Instructions

The LTSS Screening team must complete all of the following documentation requirements for individuals being screened for LTSS (NF, CCC Plus Waiver and PACE):

 

  1. The LTSS Screening team shall mail a letter to the individual screened or his or her representative indicating the LTSS determination.  Letters are required if an individual is approved or denied for services.  If denied LTSS, the individual will receive appeal rights with instructions on how to appeal the Screening team’s decision. The appeal process is described in Chapter II of this manual. 

 

  1. The approval and denial sample letters are located for LTSS Screener access on the Medicaid Web Portal under Provider Services/Provider Forms Search at: 

https://www.virginiamedicaid.dmas.virginia.gov/wps/portal.  Under Category, use the drop down menu and click on Pre-Admission Screening to access the sample letters, DMAS-P238 and DMAS-P239. 

 

  1. LTSS Screening teams are required to send the DMAS-96 Authorization Form to the local DSS benefits program (eligibility office) in the locality in which the individual resides. LDSS office contact information can be found at http://dss.virginia.gov/localagency/index.cgi

 

  1. Should the provider agency, the CCC Plus health plan or individual screened need another copy of the LTSS Screening packet, the LTSS Screening team will make copies of the completed LTSS Screening packet available during the below stated retention times.

 

  1. For adults who receive a LTSS Screening, the LTSS Screening team must retain a copy of all referenced screening documents for a period of not less than six (6) years from the date of the LTSS Screening. For children, LTSS Screening teams must retain documents for at least six (6) years after such minors have reached 21 years of ageThese documents may be electronically stored, i.e.in  eMLS

 

  1. In addition to the electronic copy of the DMAS-97, Individual Choice - Institutional Care or Waiver Services Form, a paper copy of the DMAS-97 form with the individual's or the representative's signature shall be retained in the individual's record by the LTSS Screening Team.  DMAS-97 forms are required for individuals who are authorized for LTSS. If waiver services are declined for any reason, the reason for declining shall be recorded on the DMAS-97.

 

Individual Does Not Meet NF LOC

 

If the individual does not meet the required number of dependencies or semi-dependencies/functional needs, has no medical or nursing need and/or is not at-risk for hospitalization or institutionalization, the individual is considered not to meet the NF LOC. 

 

  1. When one of the following specific care needs solely describes the individual's condition that individual is considered not to meet the required level of care need for LTSS: The individual requires minimal assistance with ADLs, including those individuals whose only need in all areas of functional capacity is for prompting to complete the activity;
  2. The individual independently uses mechanical devices such as a wheelchair, walker, crutch, or cane;
  3. The individual requires limiting diets such as a mechanically altered, low-salt, low-residue, diabetic, reducing, or other restrictive diets;
  4. The individual requires medications that can be independently self-administered or administered by the caregiver;
  5. The individual requires protection to prevent him or her from obtaining alcohol or drugs or to address a social or environmental problem;
  6. The individual requires minimal staff observation or assistance for confusion, memory impairment, or poor judgment; or
  7. The individual's primary need is for behavioral management that can be provided in a community-based setting.

 

When the individual does not meet the NF LOC, all of the following procedures apply:

 

  1. The Screening team will document this denial decision on the Member’s Case Summary, UAI B and on the DMAS-96 form, indicating that no authorization for Medicaid payment has been approved for this individual. 

NOTE:  Authorization for the LTSS is not determined by the eMLS system.  The eMLS system will accept and “Successfully Process” both authorized and non-authorized LTSS screenings.

  1. The Screening team must send a letter to the individual screened or the representative.  The individual will receive appeal rights within this decision letter providing instructions on how to appeal the Screening team’s decision, if the individual chooses.  The client appeals process is described in Chapter II of this manual.
  2. The approval and denial sample letters are located for screener access on the Medicaid Web Portal under Provider Services/Provider Forms Search at:    https://www.virginiamedicaid.dmas.virginia.gov/wps/portal.  

Use the drop down menu and click on Pre-Admission Screening to access the sample letters, DMAS-P238 and DMAS-P239. 

  1. The Screening team must send a copy of the completed DMAS-96 form to the appropriate LDSS office, benefits program (eligibility section), in order for correct financial eligibility to be determined.
  2. It is essential for LTSS Screening teams to maintain current information on available community resources, such as health services, home-delivered meals, etc., to assist in developing community alternatives to institutionalization.

Validity of Screening (PAS)

Once an individual has an approved Screening, which has been successfully processed through  eMLS, it is valid as long as the individual continues to be enrolled in Medicaid LTSS either through a NF or HCBS program. Enrollment in home and community-based services (CCC Plus Waiver and PACE) should occur as soon as possible after the completion of the LTSS screening but at least within 1 year of the LTSS Screening assessment date.  If an enrollment has not occurred in that time period another LTSS Screening must be conducted to assure the need for services including assessing  functional capacity, medical or nursing need, and documenting that without services the person would likely be hospitalized or need NF services within 30 days. 

The HCBS provider or CCC Plus health plan shall be responsible for conducting periodic evaluations to ensure that the individual continues to meet the CCC Plus Waiver or PACE criteria.   These evaluations will occur at least annually and may occur more often if the provider has a concern that the individual no longer meets the functional level of care required for Medicaid-funded LTSS or there has been a significant change in condition.

 

For individuals admitted to a NF, the NF shall be responsible for conducting periodic evaluations to ensure that the individual meets, and continues to meet, the NF LOC criteria.

Competency Training and Testing Requirements (PAS)

Beginning, July 1, 2019, each person performing the LTSS Screening and the physician signing the Medicaid LTSS Authorization Form (DMAS-96) shall complete mandatory training and testing before conducting screenings for an authorized screening entity.  A score of at least 80% on each module shall constitute satisfactory competency assessment results. At the conclusion of satisfactory completion of all modules and tests, a certificate indicating a certification number will be awarded.  This certification number must be entered each time a LTSS Screener completes submission of a LTSS Screening in eMLS.  The registration for the online, Medicaid LTSS Screening training may be found at: https://medicaidltss.partnership.vcu.edu/register 

 

This training shall be repeated no less than every three years.  The most current competency assessment results shall be kept in the Screening entity’s personnel records for each staff member performing LTSS Screenings and signing/certifying the LTSS Screening packet.  Training documentation shall be provided to DMAS upon request.  Failure to comply with the training and competency assessment requirements may result in retraction of Medicaid LTSS Screening payments. 

Screening for Medicaid-Funded LTSS Resources and Questions (PAS)

Additional information about the Medicaid LTSS Screening process may be found on the DMAS web portal at:

https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/PreAdmission.

 

List of Medicaid Memos Applicable to Screenings

 

  • October 3, 2012: Development of Special Criteria for the Purposes of PAS

Content from this memo has been updated, reformatted and incorporated into this chapter.

 

https://www.virginiamedicaid.dmas.virginia.gov/wps/portal.

January 9, 2020: Final Exempt Action Pertaining to Medicaid Long-Term Services and Supports Screening Removal of Three-Day Allowance After Hospital Discharge

May 19, 2020: Availability of Physician Training for Medicaid LTSS

Attachment A: Crosswalk for Combination Determinations (PAS)

Behavior and Orientation are considered as a combination for service authorization. Please see the chart below that provides the combinations that determine whether or not an individual is independent (I), semi-dependent (d), or dependent (D) in both behavior and orientation for the purposes of Screening for Medicaid-funded LTSS.

 

 

 

ORIENTATION PATTERN

BEHAVIOR PATTERN

Appropriate

Wandering/ Passive Less Than Weekly

Wandering/ Passive Weekly or More

Abusive/Aggressive/ Disruptive Less Than Weekly

Abusive/ Aggressive

/Disruptive Weekly or More

Oriented

I

I

I

d

d

Disoriented: Some spheres Some of the time

I

I

d

d

D

Disoriented: Some spheres All of the time

I

I

d

d

D

Disoriented: All

spheres Some of the time

d

d

d

D

D

Disoriented: All spheres All of the time

d

d

d

D

D

 

Comatose

D

D

D

D

D

 

Reminder: An individual must meet all criteria to meet NF LOC, i.e. the individual has limited functional capacity, medical or nursing needs, and is at imminent risk of NF placement within 30 days without services.

Attachment B: Worksheet to Determine Need for Medicaid-Funded LTSS (PAS)

The following worksheet is a helpful tool in determining if an individual, adult or child, meets NF LOC criteria.

 

Individual being assessed: _____                      ____________ Date: __    _____________

 

 

STEP 1: Based on a completed Virginia Uniform Assessment Instrument (UAI) - check how the individual scores in the following categories.

 

ADLs

Check If Independent (I)

Check if Semi-Dependent (d)

Check if Dependent (D)

Bathing

 

 

 

Dressing

 

 

 

Toileting

 

 

 

Transferring

 

 

 

Eating/Feeding

 

 

 

Bowel

 

 

 

Bladder

 

 

 

 

 

STEP 2: Number of “Other” Dependencies      

                          

OTHER

Check If Independent (I)

Check If Semi-Dependent (d)

Check If Dependent (D)

Medication Administration

 

 

 

Mobility

 

 

 

 

Joint Motion

 

 

 

 

Behavior Pattern & Orientation

 

 

 

 

 

 

STEP 3: Apply the responses in Step 2 to the criteria below. 

To be considered to meet the functional capacity requirements for NF level of care an individual must meet the minimum requirements of one of the following three categories.

 

CATEGORY 1:  Individuals must meet items #1 and #2 in category 1; plus either item #3 or #4.

               1) Rated dependent in 2 or more ADLs:                                                        ___ YES; PLUS

               2) Rated semi-dependent or dependent in behavior pattern and orientation

                        (behavior pattern and orientation are rated jointly)                               ___ YES; PLUS

               3) Rated semi-dependent or dependent in joint motion                                 ___ YES; OR

               4) Rated dependent in medication administration:                                        ___ YES.

                                   

               CATEGORY 2: Individuals must meet all items in this category.

            1) Rated dependent in 5 to 7 ADLs:                                                               ___ YES; PLUS

            2) Rated dependent in mobility:                                                                     ___ YES.

 

               CATEGORY 3: Individuals must meet all items in this category.

            1) Rated semi-dependent or dependent in 2 or more ADLS:                         ___ YES: PLUS

         [If individual are rated as DEPENDENT and/or SEMI-DEPENDENT (combination) in 2-7 ADLs it counts as a yes.]

            2) Rated dependent in mobility:                                                                     ___ YES, PLUS

3) Rated dependent in behavior and orientation:                                           ___ YES.

 

STEP 4: Individuals MUST have a medical or nursing need to meet criteria for LTSS. 

 

This means: 

1) the individual’s medical condition requires observation and assessment to assure evaluation of needs due to an inability for self-observation or evaluation; OR

2) the individual has complex medical conditions that may be unstable or have the potential for instability; OR

3) the individual requires at least one ongoing medical or nursing service.  (See the Screening for LTSS manual section for examples and additional explanation.)

 

Does individual does have medical nursing needs?                                             ___ YES

If YES (briefly describe):

 

STEP 5: Determination of whether the individual meets criteria for long-term services and supports. 

 

1.  Individual meets at least one of the three categories in Step 3:                      ___      YES

2.  Individual has medical or nursing needs as defined in Step 4:                      __        YES

3.  Individual meets the definition of ‘‘at risk” for institutionalization within 30 days: __YES

 

This individual meets NF LOC criteria (i.e., 1. 2. and 3. above are answered “YES”):

  ___ YES                 ___ NO

 

Assessor: ______________________________________________  Date: _______________