alzheimer's waiver documentation requirements
DESCRIPTION
Department of Medical Assistance Services. Alzheimer's Waiver Documentation Requirements. Department of Medical Assistance Services Division of Long-Term Care 2013 revisions. http://dmasva.dmas.virginia.gov. 1. Department of Medical Assistance Services. Today’s Training Objectives. - PowerPoint PPT PresentationTRANSCRIPT
http://dmasva.dmas.virginia.gov/ 1
Department of Medical Assistance Services
Department of Medical Assistance ServicesDivision of Long-Term Care
2013 revisions
http://dmasva.dmas.virginia.gov 1
Department of Medical Assistance Services
Alzheimer's Waiver Documentation Requirements
http://dmasva.dmas.virginia.gov/ 2
Department of Medical Assistance Services
Today’s Training Objectives• Waiver overview and revised regulations• To review the Alzheimer Waiver Criteria• To review documentation requirements for
recipients' admission into the waiver• To review additional required
documentation/forms • To review quality management review
documentation requirements• To discuss discharge from the waiver• Question and Answer
2
Department of Medical Assistance Services
http://dmasva.dmas.virginia.gov
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Department of Medical Assistance Services
Overview• The Alzheimer Waiver was implemented
on June 1, 2006. • The purpose for this waiver was to allow
participants to: Remain in a home-like setting for as long as
possible
Remain in an environment that maximizes their autonomy, privacy, and dignity, even if they
require a high level of services
Provide relief for family caregivers
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Department of Medical Assistance Services
Revised Regulations• Revised regulations for the AAL Waiver
was signed by the Governor and becameeffective July 5, 2012.
• This change was made to bring the Department of Social Services (DSS) licensing standards and the Department of Medical Assistance Services (DMAS) waiver regulations more in sync with each other.
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Department of Medical Assistance Services
Revised Regulations• Changes in the regulations include:
– The RN requirement has changed to licensed health care professional (LHCP). Any health care professional currently licensed by the relevant health regulatory board of the Dept of Health Professions of the Commonwealth who is practicing within the scope of his license.
– Medication administration shall only be administered by an employee who is currently licensed or registered to administer medications.
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Department of Medical Assistance Services
Revised Regulations- Nursing evaluations has changed to
Individual summaries to be completed by the LHCP.
- The activity requirement is consistent with the DSS regulations 22VAC40-72-1100. In addition, the one-on-one activity may be rendered by licensed or volunteer staff as determined appropriate by the provider.
- Direct care staffing must comply with the DSS regulations for staffing requirements in the specialty care unit.
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Department of Medical Assistance Services
Revised Regulations• Details concerning all the current AAL
Waiver changes and additions can be found in:
12VAC30-120-1600 through 12VAC30-120-1660Adding 12VAC30-120-1605, 12VAC30-120-
1670,12VAC30-120-1680.
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Department of Medical Assistance Services
Today’s Training Objectives• Waiver overview and revised regulationsTo review the Alzheimer Waiver Criteria• To review documentation requirements for
recipients' admission into the waiver• To review additional required
documentation/forms • To review quality management review
documentation requirements• To discuss discharge from the waiver• Question and Answer
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Department of Medical Assistance Services
Qualifying CriteriaIndividuals who are seeking admission into the Alzheimer Waiver must meet the following criteria found in 12VAC30-120-1610:
1. The individual must be either:– A. Elderly as defined by § 1614 of the Social Security Act; or– B. Disabled as defined by § 1614 of the Social Security Act.
2. The individual must meet the criteria for admission to a nursing facility as determined by a preadmission screening team using the full UAI.
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Department of Medical Assistance Services
Qualifying Criteria3. The individual must have a diagnosis of Alzheimer’s
or a related dementia as diagnosed by a licensed clinical psychologist or a licensed physician. The individual may not have a diagnosis of mental retardation/intellectual disability as defined by the American Association on Intellectual and Developmental Disabilities, or a serious mental illness as defined in 42CFR483.102(b)
4. The individual must be receiving an auxiliary grant, and residing in or seeking admission to a safe, secure unit of a DMAS approved assisted living facility.
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Department of Medical Assistance Services
Today’s Training Objectives• Waiver overview and revised regulations• To review the Alzheimer Waiver CriteriaTo review documentation requirements for
recipients' admission into the waiver• To review additional required
documentation/forms • To review quality management review
documentation requirements• To discuss discharge from the waiver• Question and Answer
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Department of Medical Assistance Services
Alzheimer's Assisted Living WaiverPreauthorization Process• Preauthorization is required for all individuals requesting
the Alzheimer Waiver service. • Providers must submit documentation to the designated
preauthorization contractor within 10 business days of initiating care.
• If the required information is not submitted by the provider within the 10 business days of initiating care, the service may be authorized beginning with the date all required information was received by the designated authorization contractor. In any event, the authorization cannot precede the date of the preadmission screening teams physician’s signature.
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Department of Medical Assistance Services
Alzheimer's Assisted Living WaiverPreauthorization ProcessThe required forms for preauthorization are as follows:
1. A DMAS 96- Completed by the Community Screening Team or Hospital Screener. (Signed and dated by
screeners and physician) 2. A completed 12 page Uniform Assessment Instrument
(UAI)3. History and Physical4. Documentation of Alzheimer’s diagnosis – DMAS 4155. Verification of Auxiliary Grant Status6. DMAS 480
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Department of Medical Assistance Services
DMAS 480 Alzheimer’s Assisted Living Authorization Request
Helpful Hint:Must be signed, datedBe sure to include Medicaid number and the correct Atypical Provider Identifier
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Department of Medical Assistance Services
Uniform Assessment InstrumentHelpful Hint:Make sure screening dateis in top right hand cornerBe sure a medical/nursing need is indicated on page 7
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Department of Medical Assistance Services
DMAS 96
Helpful Hint:Make sure the Medicaid Authorization is either 1 which authorizes nursing facility, 4 which authorizes the Elderly or Disabled Waiver with Consumer Direction, or 16 which authorizes the AAL waiverMake sure it is signed by, RN, MD,and SW
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Department of Medical Assistance Services
DSS Notice ofAction Taken
• Helpful Hint:• If the recipient is new to
the Auxiliary Grant program, this form is used to determine an effective date.
• Payment for the AAL waiver can not begin before the AG effective date.
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Department of Medical Assistance Services
DSS 032-05-007/8Helpful Hint:• Please submit the most
recent exam with youradmission packet
• Carefully review the list ofprohibitive conditions
• Recipient name should be on each page of document
• Make sure it is signed by facility representative
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Department of Medical Assistance Services
Alzheimer's Assisted Living WaiverPreauthorization Process
• All requests for authorization must sent to DMAS or the authorized contractor for approval. KePro is the current contractor. KePro contact information is:
KePro @ https://dmas.depro.orgPhone: 1-888-827-2884
OR
FAX to 1-887-652-9329
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Department of Medical Assistance Services
Today’s Training Objectives • Waiver overview and revised regulations• To review the Alzheimer Waiver Criteria• To review documentation requirements for
recipients' admission into the waiverTo review additional required
documentation/forms • To review quality management review
documentation requirements• To discuss discharge from the waiver• Question and Answer
http://dmasva.dmas.virginia.gov/ 21
Department of Medical Assistance Services
Level of Care • A level of care review is requirement for all AAL
waiver participants. (12VAC30-120-1610)
• Documentation must be submitted by the provider to DMAS for review.
• The level of care assessments are preformed to ensure the individual continues to meet the criteria for the waiver.
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Department of Medical Assistance Services
DMAS 99C Level of Care Review InstrumentHelpful Hint:• This form will be
requested annually for each participant.• Must meet nursing
facility criteria at the functional level as well as having an ongoing medical/nursing need.
• Complete all sections completely
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Department of Medical Assistance Services
DMAS 99C Level of Care Review Instrument Page 2Helpful Hints:• Some sections may not apply• Make sure there is current
medical record documentationto support Alzheimer's Diagnosis
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Department of Medical Assistance Services
DMAS 99C Level of Care Review Instrument Page 3
Helpful Hint:• The forms comes with its
own instructions• There is a place for the
participant’s name on each page
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Department of Medical Assistance Services
Today’s Training Objectives• Waiver overview and revised regulations• To review the Alzheimer Waiver Criteria• To review documentation requirements for
recipients' admission into the waiver• To review additional required
documentation/forms To review quality management review
documentation requirements• To discuss discharge from the waiver• Question and Answer
http://dmasva.dmas.virginia.gov/ 26
Department of Medical Assistance Services
Quality Management Reviews• 12VAC30-120-1660 - “DMAS shall conduct audits of
the services billed to DMAS and interview individuals living in the facility and the legally authorized representative to ensure that services are being provided and billed in accordance with DMAS policies and procedures.
• Completed on a regular basis.• The reviews are unannounced on site visits.• Review includes
– Review of documentation– Interview with resident or family
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Department of Medical Assistance Services
QMR Documentation Requirements• Individual Records
– Make sure there is:• a current diagnosis of Alzheimer’s documented on the
record• not a current diagnosis of serious mental illness or mental
retardation.
– Documentation to support medical/nursing needs and nursing facility criteria.
– LHCP must be addressing significant changes in health and documenting them in the ISP and monthly summaries.
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Department of Medical Assistance Services
QMR Documentation Requirements• Nursing Schedule for the last 3 months
– To determine awake staff
• Last 3 months of Activity calendars– Used to determine if:
• Structured group activities per week. • 1 hour of 1 on 1 activity per week scheduled.
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Department of Medical Assistance Services
QMR Documentation Requirements• 1 : 1 Activity Log
– Used to determined if 1 hour of 1:1 activity time given per week
– 1 hour does not have to be given all at one time. It can be given in 15 minute increments for example.
– Documentation must show, when it started and ended, what was done and who provided the 1:1, and how the participant responded.
• Daily Recipient Log– Indicates recipients presence in the facility daily.
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Department of Medical Assistance Services
QMR Documentation Requirements• Individual Service Plan
– Objectives must be measurable.– Close attention is being paid to Activity related
objectives especially relating to the 1:1– Must be reviewed/signed by the LHCP initially and
annually– Must be updated quarterly
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Department of Medical Assistance Services
ISP – Example of Measurable Goals
Complete goalParticipant will actively participate in 3 out of 4 group activities weekly.
Participant will verbally respond to activity personnel during 3 out of 4 1 on 1 sessions weekly
Participant will choose clothing 7 out of 7 days per weekParticipant will dress self 7 out of 7 days per week
Inadequate GoalParticipant will participate in activities of choice (too vague)
Participant will be visited 1 hour each week(too general)
Participant will be clean and dressed everyday(Does not indicate what level of assistance needed)
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Department of Medical Assistance Services
QMR Documentation Requirements• Employee Records
– Hire dates– Criminal Records Check (date completed and results)– Certification date of completion or license Expiration
date– Documentation that 12 hours of dementia related
training was received within 30 days of hiring. Per 12VAC30-120-1640
– AND– Documentation of 8 hours of annual training in caring for
individuals with dementia and medical nursing need
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Department of Medical Assistance Services
QMR Documentation Requirements• Individual summaries (DMAS 483)
completed by the LHCP.– The annual summaries
and– Monthly summaries
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Department of Medical Assistance Services
DMAS 483DMAS 483 - AAL Waiver Admission Summary & Monthly Summary
Helpful Hint:• Make sure recipients name is on
each page• Circle “Admission Summary” or
“Monthly Summary”
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Department of Medical Assistance Services
DMAS 483• How to code ADL Status on the DMAS 483
– The individual does not need help (equipment or human assistance) to perform the activity. This is coded as independent
– Mechanical help only means the client needs equipment or device to complete the activity and does not need human help. This is semi-dependent .
– Mechanical help and human help is coded as dependent.
– Human help (assistance of 1 or 2 staff people) this is coded as dependent.
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Department of Medical Assistance Services
DMAS 483• How to code ADL Status on the DMAS 483
– Supervision (verbal cues, prompting). The individual is able to perform the activity without hands-on assistances of another person, but must have another person present to prompt and/or remind the individual to safely perform the complete activity. This code often pertains to people with cognitive impairment. The code is dependent.
– Physical Assistance (Set-Up, Hands On Care) Physical assistance means hands on help by another human, including assistance with set-up of the activity. This is coded as dependent.
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Department of Medical Assistance Services
DMAS 483DMAS 483 - AAL Waiver Admission Summary & Monthly Summary Page 2
Helpful Hints:• Monitor existence of prohibiting
conditions• Medical/Nursing needs
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Department of Medical Assistance Services
DMAS 483
Helpful Hint:• Must be completed by
LHCP• A change in condition here
should be reflected in a change in the ISP
• Monthly summaries must be sent to DMAS by the 10th of the Month
DMAS 483 - AAL Waiver Admission Summary & Monthly Summary Page 3
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Department of Medical Assistance Services
Today’s Training Objectives• Waiver overview and revised regulations• To review the Alzheimer Waiver Criteria• To review documentation requirements for
recipients' admission into the waiver• To review additional required
documentation/forms • To review quality management review
documentation requirementsTo discuss discharge from the waiver• Question and Answer
http://dmasva.dmas.virginia.gov/ 40
Department of Medical Assistance Services
Discharge from the Waiver • Care needs change so that placement in a
nursing facility is needed (condition worsens)• The individual is no longer eligible for
Medicaid • The individual is no longer eligible to receive
an Auxiliary Grant• The individual no longer meets waiver criteria
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Department of Medical Assistance Services
Discharge from the Waiver• The individual has been absent from the
assisted living facility for greater than 30 consecutive calendar days
• The individual’s environment does not provide for their health, safety, and welfare
• The assisted living facility no longer meets safe and secure licensing standards set by DSS or standards set by DMAS for service providers
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Department of Medical Assistance Services
Discharge from Waiver• If a recipient is discharged from the facility
and admitted to a nursing facility and then wants to return to ALF into the AAL waiver, a new package must be completed and submitted.
• Additionally, the provider must ensure resident is still in compliance with Auxiliary Grant requirements upon return.
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Department of Medical Assistance Services
Today’s Training Objectives• Waiver overview and revised regulations• To review the Alzheimer Waiver Criteria• To review documentation requirements for
recipients' admission into the waiver• To review additional required
documentation/forms • To review quality management review
documentation requirements• To discuss discharge from the waiverQuestion and Answer
http://dmasva.dmas.virginia.gov/ 44
Department of Medical Assistance Services
Provider Call CenterClaims, covered services, billing
inquiries:
800-552-8627 804-786-6273
8:30am – 4:30pm (Monday-Friday)11:00am – 4:30pm (Wednesday)
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Department of Medical Assistance Services
Department of Medical Assistance ServicesLong Term Care DivisionTelephone number – 804-225-4222Fax number- 804-612-0040Web portal-
www.virginiamedicaid.dmas.virginia.gov