Documentation & Forms Required by State of VA for Care Coordination

COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

COMMONWEALTH COORDINATED CARE PLUS MCO CONTRACT FOR MANAGED LONG TERM SERVICES AND SUPPORTS

January 1, 2018 - December 31, 2018

of a birth certificate or an identification card or driver's license; and other reasonable one-time expenses incurred as part of a transition.

Transition Services are furnished only to the extent that they are reasonable and necessary as determined through the transition plan development process, are clearly identified in the transition plan and the person is unable to meet such expense, or when the services cannot be obtained from another source. See Care Coordination with Transitions of Care.

4.7.2.16 Service Authorizations Initial Service Authorizations (SA) as well as SA renewals shall comply with requirements in the Service Authorization section of this Contract. Refer to the Model of Care, Health Risk Assessments and Person-centered Individualized Care Plans section of the Contract for more information.

4.7.2.17 Documentation Requirements The following is the minimum documentation to be retained in the Member’s Record by the Contractor’s Care Coordinator. The Department reserves the right to adjust the chart as regulations and/or policy manuals are changed. DMAS forms may be found on the DMAS web portal at: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderFormsSearch .

Documentation RN Supervisory Visit

Frequency Monthly for technology dependent Members; Quarterly for all others Every 60 calendar days

Plan of Care (CMS-485) Plan of Care (DMAS 97 A/B)

Every 12 months or more frequently as needs change

Telephone Communications with individuals/caregivers, providers, physicians, etc.

Initial Screening (UAI, DMAS-95 [as applicable], DMAS-96, DMAS-97, 99-LOC, DMAS 108/109 as appropriate, MD order for Tech subgroup admission, etc. as applicable) Updated Screening Hospital summaries, discharge orders, additional medical record information (i.e. tests, procedures, etc.)

Service Authorization Documentation Correspondence with Individual/Caregiver (letters) Medicaid LTC Communication Form (DMAS 225) Health Risk Assessment

57

Daily or as needed

On admission Lapse of LTSS services >30 calendar days Hospital admissions, change in health status Yearly, Change in hours or provider Enrollment, Disenrollment, Change in provider, Change in hours Enrollment, Disenrollment Refer to the Model of Care Assessment and Individualized Care Plan Expectations table

Department of Medical Assistance Services Division for Aging and Disability Services PRIVATE DUTY NURSING ADULT REFERRAL FOR THE COMMONWEALTH COORDINATED CARE PLUS (CCC Plus) WAIVER Adults (21 years or >) must meet Criteria Group A or all Criteria Group B to qualify for Private Duty Nursing (PDN) Services.

Individual’s Name ___________________________Phone______________________ Date_________________ Address __________________________________ Medicaid #________________________________________ Referral Source ____________________________ Phone # __________________________________________ Form Completed By_________________________ Phone # _________________________________________ Signature of Person Completing Form___________________________________________________________ TECHNOLOGY / SKILLED CARE Criteria Group A - Ventilator

YES

NO

Document Orders Below Ventilator Orders

Ventilator Dependent at least a portion of the day Criteria Group B – Complex Tracheostomy Has a tracheostomy with the potential for weaning or documentation of the inability to wean Treatment Orders Requires nebulizer treatments and chest physiotherapy (PT) at least four times per day OR nebulizer treatments at least four times a day provided by a licensed nurse or respiratory therapist Treatment Orders Requires pulse oximetry monitoring at least every shift due to demonstrated unstable oxygen saturation levels Requires respiratory assessment and documentation every shift by a licensed nurse or respiratory therapist Treatment Orders Has a physician’s order for oxygen therapy with documented usage Treatment Orders Requires tracheostomy care at least daily Has a physician’s order for tracheal suctioning as needed Is deemed at risk of requiring subsequent mechanical ventilation DMAS/CCC Plus Health Plan has the final authority to authorize nursing hours. ______________________ Criteria

Group A

(OR)

B

Approved Skilled PDN Hours/ Week _________________________

Comments: __________________________ __________________________

RN Coordinator/Reviewer Signature____________________________Date_______________________________ DMAS-108 (Rev. 4-2019)

Department of Medical Assistance Services Division for Aging and Disability Services Adult Referral Instructions Adults (21 and older) are eligible for Private Duty Nursing Services if they meet Nursing Facility Specialized Care criteria, Group A - Ventilator Dependence (or) Group B - Complex tracheostomy All criteria. (Refer to PDN Adult Referral Form) Adults (21 years or >) are assessed by the Medicaid Long-term Services and Supports Screening team on this form for eligibility for CCC Plus Waiver PDN. Screeners will submit the Screening and this form. RN Supervisors/CCC Plus Care Coordinators will complete this form annually for level of care reviews and whenever there are major changes in the individual’s medical or technical skilled needs.

When completing the adult referral form, check the technology needs of the individual and document the physician’s orders for care under the appropriate sections of the form.

Criteria Group A - Ventilator The ventilator dependent criteria are met when an individual is on a ventilator for any portion of the day.

Document physician’s ventilator orders in the appropriate block in the right side column.

Criteria Group B – Complex Tracheostomy

(MUST MEET ALL CRITERIA IN THIS GROUP)

Potential for weaning – Individuals who are unable to wean from a tracheostomy meet this criteria.

Requires nebulizer treatments and chest physiotherapy (PT) at least four times per day OR nebulizer treatments at least four times a day. Document treatment orders in the appropriate block on the right side of the form.

Pulse oximetry readings are required every nursing shift. Document physician’s pulse ox orders in the appropriate block.

Skilled nursing or respiratory assessments are required every shift due to respiratory insufficiency.

Individuals meet oxygen use criteria when oxygen is needed continuously at least 8 hours per day.

Document physician’s oxygen orders in the appropriate box.

The individual must require tracheal care at least daily. Document physician’s trach care orders in the adjacent box.

A physician’s order for tracheal suctioning as needed (PRN) is required. Suctioning is defined as tracheal suctioning requiring a suction machine and flexible catheter.

Individuals must be at risk of requiring ventilator support.

If further help is needed questions may be sent to: LOCReview@dmas.virginia.gov

DMAS-108 (Rev. 4-2019)

Department of Medical Assistance Services Division for Aging and Disability Services PRIVATE DUTY NURSING PEDIATRIC REFERRAL FOR THE COMMONWEALTH COORDINATED CARE PLUS (CCC Plus) WAIVER Score daily nursing and technology needs to determine eligibility for Private Duty Nursing level of service.

Children (<21 years old) must receive a minimum score of 50 points.

Individual’s Name____________________________________ Phone______________________ Date ___________ Address ____________________________________________Medicaid #__________________________________ Referral Source______________________________________ Phone# _____________________________________ Form Completed By __________________________________ Phone # ____________________________________ Signature of Person Completing Form_______________________________________________________________ Technology Ventilator Ventilator Tracheostomy C-PAP, BIPAP Oxygen Oxygen Continuous Peritoneal Dialysis J/G Tube J/G Tube continuous NG Tube NG Tube IV Therapy

Frequency Continuous Intermittent

Continuous With Reflux

Points 50 45 43 25 15 35 45 15 35

Continuous Bolus Continuous

40 25 40

Continuous Unstable Sats

Score

Intermittent Catheter

Dressings Tracheostomy Care IV / Hyperal

Subtotal Technology Score

Nursing Needs

Frequency

Points

Tracheal Suctioning

>Q1hr.

Q1-4hrs Q4hrs.

Continuous Q2hrs Q3hrs Q4hrs

5 3 2 5 4 3 2

Enteral Feedings

Nursing Needs

Frequency

Points

Daily Medications Excluding nebulizers

Score

Special Treatments (Nebs, chest PT)

3 or less meds 4-5 meds

2 4

6 or more Q4hrs

8 8

Q8hrs Q12hrs Q Day or PRN Q8hrs or less > Q8hrs

6 4 2 3 2 5 8 6 4 2 8 6 4 2 5

Continuous 8-16hrs 4-7hrs < 4 hrs QID TID BID Q Day

Special monitor I&O Other Subtotal Nursing Score Total Technology and Nursing Score Score

DMAS/CCC Plus Health Plan has the final authority to authorize nursing hours.

RN COORDINATOR’S AUTHORIZATION Score Categories:

Total Technology / Skilled Nursing Score________________ Approved Nursing Hours / Week_______________________ RN Coordinator/ Reviewer Signature _________________________________________________ Date_____________________________________________

¨A

50-56 points – Nursing 70 hours/ week

¨B

57-79 points – Nursing 84 hours/ week

Comments: __________________________________________________

¨C

80 or more - Nursing 112 hours/ week

__________________________________________________ __________________________________________________

DMAS - 109 (Rev. 4-2019)

Department of Medical Assistance Services Division for Aging and Disability Services Page 1 of 3

Pediatric Referral Instructions 1.

Children (<21 years old) are scored by the Medicaid Long-Term Services and Supports Screening team on this form to refer for CCC Plus Waiver PDN services. Screeners will submit the Screening and this form. RN Supervisors/CCC Plus Care Coordinators will complete this form annually for level of care reviews and whenever there are major changes in the individual’s medical or technical skilled needs.

2. Children must receive a minimum score of 50 points on the Pediatric Referral form (DMAS 109) for admission and to continue on the waiver under PDN services.

3. Children must receive a score in the technology section of the form to qualify for PDN services.

Scores in the technology section are adjusted to reflect the risk of death or disability if the technology stops as well as the degree of nursing assessment or judgment needed to operate the technology. Scores in the nursing needs section reflect the time needed to perform the skill.

4. Ventilator dependent children receive the technology score for ventilator regardless of the settings or type of support the ventilator is providing. BiPaP machines with an ordered breath rate will also receive the technology score for ventilator.

5. Oxygen is considered continuous when needed at least 8 hours per day. Additional points are awarded for unstable oxygen if children have continuous 24 hour per day oxygen use, and any two (2) of the following conditions: • • • • • •

Diuretic use Albuterol treatments at least 4hrs around the clock Weight is below 15th percentile for age and gain does not follow normal curve for height Greater than three (3) hospitalizations in the last six (6) months for respiratory problems Daily desaturations below physician ordered parameters and requiring nursing intervention Physician ordered fluid intake restrictions

6. J/G-tube bolus feedings do not receive points in the Technology section of the DMAS 109 form.

J/G-tube feedings are considered continuous when received via pump at least 8 hours/day.

Children qualify for increased J/G-tube continuous with reflux points with one (1) of the following documented: • • •

Swallow study that documents reflux within the last six (6) months Treatment for aspiration pneumonia in the past twelve (12) months Need for suctioning due to reflux at least daily (includes oral suctioning)

7. Suctioning is defined as pharyngeal or tracheal suctioning requiring a suction machine and flexible catheter. Nursing needs are assigned points based on the frequency of the need for the activity, i.e. trach suctioning q1hr. The child’s nursing record must support the chosen frequency.

Suctioning frequency should not be based on a period when a child has an infection or other acute respiratory illness but when he/she is at their normal baseline status. A child is ineligible for points in the suctioning category if he/she is able to suction their own trach.

Page 2 of 3 DMAS - 109 (Rev. 4-2019)

Department of Medical Assistance Services Division for Aging and Disability Services

Pediatric Referral Instructions 8. Medication points are awarded based on the complexity of the child’s medication regimen: • • •

3 or less medications = simple category (2 points) 4 or 5 medications = moderate category (4 points) 6 or more medications = complex category (6 points)

PRN or “as needed” medications are not counted when determining the appropriate medication category.

Nebulizer treatments do not count as medications, they are considered special treatments (see #10).

9. Dressing points are assigned depending on frequency of care for sterile dressing changes and wound care for stages II, III, or IV wounds. Dressing points are not assigned for tracheostomy tubes, gastrostomy tubes, etc. as these points are included in other sections.

10. Special treatments include routine nebulizer treatments, chest PT, blood sugar checks, INR checks (at home), colostomy/ileostomy/urostomy care, etc. Treatments must require a skilled professional. ROM or splint applications are not considered special treatments. Treatments that are done together, such as nebulizer treatments followed by chest PT three times per day (TID), would be assigned TID points (6 pts.)

Children receiving single or multiple different treatments four (4) or more times per day would receive QID points (8pts.) The maximum awarded in this category is eight (8) points no matter how many treatments are performed.

11. Specialized I/O monitoring is reserved for those who need careful monitoring of intake and output due to significant conditions such as kidney problems, severe dumping syndrome or peritoneal dialysis. Children are eligible for these points if I & O results require action on the part of the nurse to make adjustments in tube feeding amounts or IV fluid rates. Normally this monitoring would be due to the need for replacement fluids if the output is too high.

12. The “Other” category is for major procedures that are not covered elsewhere on the form.

Children with needs that are not covered on the referral form should be discussed with a DMAS/CCC Plus Care Coordinator who will assign a point score for the “Other” category.

13. Assign points in all relevant categories and record the total points at the bottom of the page.

14. Skilled nursing hours should decrease when there is a decrease in a child’s total points indicating medical improvement.

If further help is needed questions may be sent to: LOCreview@dmas.virginia.gov

Page 3 of 3

DMAS - 109 (Rev. 4-2019)

Community-Based Care Level of Care Review Instrument Assessment Date: ______/________/______

Provider Information Provider Name: _______________________________________________________________________________ Provider ID#: _______________________________

Add’l Provider ID# (EDCD Only): ___________________

Provider’s Phone: (_______)_______-_________

Provider’s Email Address: _________________________

Provider’s Street Address: ________________________________________________________________________ Provider’s City: _________________________________ Provider’s State: ____________ Provider’s Zip: ________ Program Type:

Alzheimer’s Assisted Living Waiver

EDCD Waiver

Technology Assisted Waiver

PACE

For PACE Enrollments ONLY: Initial Enrollment

Unscheduled Assessment

6-Month Reassessment

Enrollment Agreement Signed: ______/_______/_______

Annual Assessment

UAI Completed Date: ______/_______/_______

For EDCD Enrollments ONLY: Service Delivery Method:

Agency Directed

Consumer Directed

Both

Individual’s Personal Information/ Demographics Name (Last, First, MI): ________________________________________________________________________________ SSN: ____-_____-_____ Marital Status: Race:

Date of Birth: ______/_______/_______

Divorced

Married

African American

Gender:

Male

Separated

Asian American

Single

Hispanic American

ALF

Apartment

Rent House

Live w/Family

Unknown Other

Widowed White American

City: __________________ State: VA

Nursing Facility

Rented Room 1

DMAS-99LOC

Phone: (_______)_______-______

Female

Address: ____________________________________________ Housing:

Age: _____

Other

Zip: _______

Own House

CBC Level of Care Review Individual’s Name: __________________________

Assessment Date: ___/____/_____

Name of Unpaid Primary Caregiver (Not applicable to Alzheimer’s Waiver): ______________________________________ Advance Directive:

Yes

No

APS/CPS Referral:

Yes

No

History of Substance Abuse:

Yes

No

Discharge Information If the individual has been discharged, expired or transferred – please enter the last date of service: _____/______/_______ Please provider the service authorization number(s) issued for your Provider ID: ____________________ Additional Service Authorization (EDCD Only): ____________________ *Note: If this section is completed, no other information is necessary. Please go to the last page and sign to complete the review.

Service Information Check all that apply: Personal Care

Number of hours per day: ___________________

Respite Care

Number of hours per day: ___________________

Private Duty Nursing

Number of hours per day: ___________________

Adult Day Care

Number of days per week: ___________________

DME

Home Delivered Meals

Personal Emergency Response System (PERS)

Home Health Nursing

Speech

OT

Speech

OT

PT

Other

Rehab At Center Nursing

PT

Other

Communication of Needs Speech

Hearing Impaired

Visually Impaired

Language Spoken English

Other

Specify Other:

____________________________________

2

DMAS-99LOC

CBC Level of Care Review Individual’s Name: __________________________

Assessment Date: ___/____/_____

Financial Resources Check all that apply: Medicaid Insured

Medicaid ID #: ___________________

Medicare Insured

Medicare #: _____________________

Private Insurance

Company: ______________________ Policy #: _________________________

Private Pay

Functional Status ADLs

(Select Appropriate Level)

Bathing:

Needs No Help Mechanical Help (MH) Only Human Help - Supervise Human Help – Physical Assistance MH & Human Help - Supervise MH & Human Help - Physical Assistance Always Performed By Others

Dressing:

Needs No Help Mechanical Help (MH) Only Human Help - Supervise Human Help – Physical Assistance MH & Human Help - Supervise MH & Human Help - Physical Assistance Always Performed By Others Is Not Performed At All

3

DMAS-99LOC

CBC Level of Care Review Individual’s Name: __________________________

Toileting:

Assessment Date: ___/____/_____

Needs No Help Mechanical Help (MH) Only Human Help - Supervise Human Help – Physical Assistance MH & Human Help - Supervise MH & Human Help - Physical Assistance Always Performed By Others Is Not Performed At All

Transferring:

Needs No Help Mechanical Help (MH) Only Human Help - Supervise Human Help – Physical Assistance MH & Human Help - Supervise MH & Human Help - Physical Assistance Always Performed By Others Is Not Performed At All

Eating/Feeding:

Needs No Help Mechanical Help (MH) Only Human Help - Supervise Human Help – Physical Assistance MH & Human Help - Supervise MH & Human Help - Physical Assistance Spoon Fed Syringe/Tube Fed Fed by IV

Continence

Bowel:

(Select Appropriate Level)

Continent External Device/Indwelling/Ostomy (Self Care) Incontinent (Less Than Weekly) Incontinent (Weekly or More) Ostomy (Not Self Care)

4

DMAS-99LOC

CBC Level of Care Review Individual’s Name: __________________________ Bladder:

Assessment Date: ___/____/_____

Continent External Device (Not Self Care) External Device/Indwelling/Ostomy (Self Care) Incontinent (Less Than Weekly) Incontinent (Weekly or More) Indwelling Catheter (Not Self Care) Ostomy (Not Self Care)

IADLs

(Check all that apply ‘yes’ = needs assistance)

Meal Preparation:

Yes

No

Housekeeping:

Yes

No

Laundry:

Yes

No

Money Mgmt:

Yes

No

Transport:

Yes

No

Shopping:

Yes

No

Using Phone:

Yes

No

Home Maint:

Yes

No

Physical Health Assessment Joint Motion:

(Select Appropriate Level) Within normal limits or instability corrected (0) Limited motion (1) Instability uncorrected or immobile (2)

Medicine Administration/

Without Assistance (0)

Take Medicine:

Administered/monitored by lay person (1) Administered/monitored by professional nursing staff (2)

Orientation:

Oriented Disoriented – Some Spheres/Sometimes Disoriented – Some Spheres/All Times Disoriented – All Spheres/Sometimes Disoriented – All Spheres/All Times Semi-Comatose/Comatose

Behavior:

Appropriate Wandering/Passive Less Than Weekly Wandering/Passive Weekly or More Abusive/Aggressive/Disruptive Less Than Weekly Abusive/Aggressive/Disruptive Weekly or More Semi-Comatose/Comatose

5

DMAS-99LOC

CBC Level of Care Review Individual’s Name: __________________________

Ambulation

Walking:

Assessment Date: ___/____/_____

(Select Appropriate Level)

Human Help – Physical Assistance Human Help - Supervise Is Not Performed At All MH & Human Help – Physical Assistance MH & Human Help - Supervise Mechanical Help (MH) Only Needs No Help

Wheeling:

Always Performed By Others Human Help – Physical Assistance Human Help - Supervise Is Not Performed At All MH & Human Help – Physical Assistance MH & Human Help - Supervise Mechanical Help (MH) Only Needs No Help

Stair Climbing:

Human Help – Physical Assistance Human Help - Supervise Is Not Performed At All MH & Human Help – Physical Assistance MH & Human Help - Supervise Mechanical Help (MH) Only Needs No Help

Mobility:

Needs No Help Mechanical Help (MH) Only Human Help - Supervise Human Help – Physical Assistance MH & Human Help - Supervise MH & Human Help – Physical Assistance Confined Moves About Confined Does Not Move About

6

DMAS-99LOC

CBC Level of Care Review Individual’s Name: __________________________

Medical/Nursing Needs

Assessment Date: ___/____/_____

(Complete all sections)

Diagnosis (Check all that apply) Diabetes

COPD

Cancer

Dementia

Alzheimer’s

ID/DD

Other Diagnosis (Please specify)

Medications

CBC Level of Care Review

Current Health Status/ Conditions/ Comments

Current Medical Nursing Need(s):

Yes

No

If ‘Yes’, check all items that apply: Application of aseptic dressing (a) Routine catheter care (b) Respiratory therapy (c) Therapeutic exercise and positioning (d) Chemotherapy (e) Radiation (f) Dialysis (g) Suctioning (h) Tracheotomy care (i)

7

DMAS-99LOC

Congestive Heart Failure Mental Health

CBC Level of Care Review Individual’s Name: __________________________

Assessment Date: ___/____/_____

Infusion therapy (j) Oxygen (k) Routine skin care to prevent pressure ulcers for individual who are immobile (l) Care of small uncomplicated pressure ulcers, and local skin rashes (m) Use of physical (e.g., side rails, poseys, locked doors in the PACE Center) and/or chemical restraints (n) Management of those with sensory, metabolic, or circulatory impairment with demonstrated clinical evidence of medical instability (o) Routine care of colostomy or ileostomy or management of neurogenic bowel and bladder (p) 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 (q) The individual’s medical condition requires observation and assessment to assure evaluation of the person’s need for modification of treatment or additional medical procedures to prevent destabilization, and the person has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals (r) Due to the complexity created by the person’s multiple, interrelated medical conditions, the potential for the individual’s medical instability is high or exists (s) Other: Please specify ‘Other’

I acknowledge that by signing my name as the RN completing this form, I will be attesting that all information entered is accurate and correct.

Completed by: ________________________________________________________________________ (Name of RN/SF completing form)

8

DMAS-99LOC

Community-Based Care Level of Care Review Instrument Instructions This form (DMAS-99 series) must be completed in its entirety for each current waiver individual that is admitted under your Medicaid provider number. The instructions to fill out each category correctly are explained below. If you need further instructions about the meaning of a question on this form, look at the UAI manual located at: http://www.dmas.virginia.gov/ltc-Pre_admin_screeners.htm For PACE Only: The Interdisciplinary Team Plan of Care form is to be mailed to DMAS ten (10) days prior to enrollment as designated by the PACE Agreement.

Regardless of the program type, the provider must complete the annual LOC assessment. The assessment is required to be entered electronically via the DMAS Web Portal within the time frame designated in the Medicaid MEMO. Each provider will receive written notification, including a list of all of their current enrolled individuals by name and Medicaid number and the date the individual was admitted to either waiver or PACE services. All providers will be required to submit the monthly assessments via the Web Portal on or before the last day of the same month as the individual’s waiver enrollment date in MMIS. For example: Sally Jones was admitted to the EDCD Waiver on October 1, 2012- the Web Portal LOCERI assessment entry and submission date must occur before 10/31/2012. For additional information concerning the notification process and timely submission refer to the Medicaid MEMO. Any additional written information will be requested directly from DMAS and will require delivery by regular mail. Due to HIPPA requirements, DMAS cannot accept this information through electronic mail. In addition, due to the volume, fax documents are not permitted. Any paper documentation requested by DMAS may be sent via the U.S. Mail to: : Department of Medical Assistance Services, Quality Assurance Unit Division of Long Term Care – Level of Care Reviews, 600 East Broad Street, Richmond, Virginia 23219

Assessment Date: Enter the date of the last 6-month assessment that is being used to fill this form out.

Provider Name: Enter the name of the organization/agency or individual provider Provider ID#: Enter Provider ID (either NPI or API) related to the service authorization.

Provider Phone #: Enter the phone number associated with the provider’s servicing address Provider E-Mail: Enter the email address of the servicing provider Provider’s Street Address: Enter the street address associated with the provider’s servicing address Provider’s City: Enter the city associated with the provider’s servicing address Provider’s State: Enter the state associated with the provider’s servicing address

9

DMAS-99LOC

Provider’s Zip: Enter the zip code associated with the provider’s servicing address Program Type: Select the program/waiver type this form is submitted for Service Delivery Method (EDCD Waiver only): Select the appropriate service delivery method For PACE Enrollments ONLY: Select the assessment period for this submission and enter the dates the enrollment agreement was signed and the UAI was completed.

Personal Information/Demographics  Last Name: Enter the last name of the individual receiving services  First Name: Enter the first name of the individual receiving services  Middle Initial: Enter the middle initial of the individual receiving services  SSN: Enter the individual’s 9 digit social security number  DOB: Enter the individual’s date of birth  Age: Enter the individual’s age at the time of the assessment  Phone #: Enter the individual’s phone number including area code  Marital Status: Select the individual’s current marital status  Race: Select the individual’s race  Gender: Select the individual’s gender  Address: Enter the individual’s street address of residence  City: Enter the individual’s city of residence  State: Should be Virginia (VA)  Zip: Enter the individual’s zip code of residence  Housing: Select the appropriate housing scenario for the individual  Name of Unpaid Caregiver (not applicable to Alzheimer’s program types): Enter the name of an person giving care without payment  Advance Directive: Does the individual have an advance directive? Yes or No  APS/CPS Referral: Does the individual have an APS/CPS referral? Yes or No  History of Substance Abuse: Does the individual have a history of substance abuse? Yes or No Discharge Information – Complete any discharge information that is applicable for this individual  If the patient has been discharged, expired or transferred – please enter the last date of service: Enter the last day of hands on waiver services care provided by your agency.  Service Authorization Numbers: Enter the service authorization number(s) issued for your provider ID NOTE: If individual has been discharged, expired or transferred, service authorization numbers should be entered and no additional data is needed for these forms.

Service Information – Check all service information that is applicable for this individual  Personal Care: Check if individual receives/requests personal care and if checked, complete the following: o Number of hours per day: Enter the number of personal care hours per day  Respite Care: Check if individual receives/requests respite care and if checked, complete the following: o Number of hours per day: Enter the number of respite care hours per day  Private Duty Nursing: Check if individual receives/requests private duty nursing and if checked, complete the following: o Number of hours per day: Enter the number of private duty nursing hours per day  Adult Day Care: Check if individual receives/requests adult day care and if checked, complete the following: o Number of days per week: Enter the number of adult day care days per week

10

DMAS-99LOC

      

DME: Check if durable medical equipment is used/needed by the individual Home Delivered Meals: Check if individual receives home delivered meals Personal Emergency Response System (PERS): Check if individual utilizes PERS Home Health: Check if individual is utilizing home health services o Nursing, Speech, OT, PT or Other: If home health services are being used, check rather the individual is using nursing, speech, OT, PT or other services Rehab at Center: Check if individual is at a rehab facility o Nursing, Speech, OT, PT or Other: If Rehab at Center services are being used, check rather the individual is using nursing, speech, OT, PT or other services Communication of Needs: Check any/all communication impairments – speech, hearing and/or visual Language Spoken: Select the individual’s primary language o Other – If language spoken selection is ‘Other’, please specify

Financial Resources: Select any/all options that apply and complete any associated information.

Functional Status: Select the appropriate option in each category.  ADLs: Select the appropriate option.  Continence / Bowel & Bladder: Select the appropriate option.  IADLS: Select the appropriate option. These items pertain to whether the individual needs help in these areas (Yes = Needs Assistance).

Physical Health Assessment: Select the appropriate options Medical / Nursing Needs: Describe the current health status/condition of the individual and check the medical nursing need or note the nursing need(s) of the individual. Something must be checked to show individual’s Medical/Nursing eligibility.  Current Health Status/Condition/Comments: Any information on the individual’s care, medical condition, or status that relates to his/her eligibility or utilization of hours.

Completed by: This is the name of the RN completing the Care Review form. By signing, the signer is attesting that all information entered is accurate and correct.

11

DMAS-99LOC

Applicant’s Name: ______________________________________ Date: _______________________

The Virginia Department of Medical Assistance Services: Questionnaire To Assess An Applicant’s Ability to Independently Manage Consumer-Directed Services To The Assessor: In addition to reviewing the applicant’s ability to answer questions on the Uniform Assessment Instrument (UAI) regarding his or her status and care needs, it is necessary to question the applicant in the following areas and document the response.

I.

II.

Daily Decision-Making 1. Did you pick out the clothes you are wearing? Please explain how you select what clothing you will wear for the day.

2.

How do you plan or arrange for your meals? What kinds of things do you eat for breakfast, lunch, and dinner?

3.

How do you manage your finances (pay your bills)?

4.

What do you do everyday? Please tell me your daily routine.

Short- and Long-Range Planning 1.

How often do you have to leave the house? If you do leave the house, how do you make appointments or schedule transportation? What transportation do you use?

2.

How do you plan for a future event (for example, Christmas, family visits, etc?)

Questionnaire To Assess An Applicant’s Ability to Independently Manage Consumer-Directed Services (Continued)

DMAS-95 Addendum (080105) Page 1 of 3

Applicantâ&#x20AC;&#x2122;s Name: ______________________________________ Date: _______________________ III.

Finding a Personal Assistant/Care Aide 1.

How will you find and hire someone to be your personal assistant/aide? What kind of person will you need to take care of your needs?

2.

How will you find a replacement if a personal assistant/aide fails to come to work or quits without notice? How will you manage until you can find another aide?

3.

What would you do to let someone know you needed assistance if your personal assistant/aide does not show up?

4.

What steps would you take if your personal assistant/aide was abusive, or you thought the personal attendant was stealing from you?

IV. Health Knowledge/Supports 1. What kind of medical problems do you have? How are you currently taking care of these needs (i.e., are you seeing a doctor?) If you needed to talk to someone about a medical problem, whom would you call?

2.

What kind of medications do you take and how often do you take them? What are they for?

3.

Who will be providing for your medical needs other than your personal assistant/aide?

Questionnaire To Assess An Applicantâ&#x20AC;&#x2122;s Ability to Independently Manage Consumer-Directed Services (Continued) V.

Support Network 1.

Do you have additional support available from family, neighbors, friends, school or employers who

DMAS-95 Addendum (080105) Page 2 of 3

Applicantâ&#x20AC;&#x2122;s Name: ______________________________________ Date: _______________________ can contact in case you have an emergency? If so, whom? How would you contact them?

Pre-Admission Screening Team Recommendation:

I recommend the applicant receive Consumer-Directed (CD) Services based on: 1) The applicantâ&#x20AC;&#x2122;s demonstrated ability to supervise a personal assistant/ aide; and/or 2) The applicant has adequate accommodations/support that enables him or her to manage services independently. The applicant will receive personal care aide management training prior to receiving CD services.

Additional Comments:

(This section is applicable for applicants, who are knowledgeable about their own care, can communicate their needs to a personal care aide, and understands the rights, risks, and responsibilities of Medicaid-Funded CD services. The applicantâ&#x20AC;&#x2122;s responses to issues related to daily decision-making, short- and long-range planning, finding an aide, health knowledge/supports, and support networks demonstrate that the applicant is capable of handling the responsibilities associated with consumer-directed services. Factors which should not influence this decision include, but are not limited to the inability to read and/or write due to a print impairment, educational level, the inability to communicate verbally, or the lack of previous experience in managing his or her health services.)

I do not recommend the applicant receive CD services in the Medicaid Waiver. The applicant has little or no knowledge of his or her care requirements and could not assume the responsibilities of consumerdirected services at the present time. The applicant will be offered alternative Medicaid-funded long-term care options.

Additional Comments:

(This section is applicable if the applicant has little or no knowledge of his or her care requirements or consumer-directed program responsibilities. Responses in the areas of daily decision-making, short- and longrange planning, finding a personal assistant/aide, health knowledge/supports, or support networks given by the applicant do not demonstrate that the recipient would be capable of meeting program requirements of the Waiver and successfully managing CD services.)

Assessor Signature/Title:

DMAS-95 Addendum (080105) Page 3 of 3

Date:

MEDICAID FUNDED LONG-TERM SERVICES AND SUPPORTS (LTSS) AUTHORIZATION FORM I. INDIVIDUAL INFORMATION:

Last Name: ________________________________ First Name: _____________________ Birth Date: ____/____/________ Social Security_____________________________ Medicaid ID ________________________

Gender: __________

II. MEDICAID ELIGIBILITY INFORMATION: Is Individual Currently Medicaid Eligible?

1 = Yes 2 = Not currently Medicaid eligible but anticipated to be financially eligible within 180 days of nursing facility admission 3 = Not currently Medicaid eligible, nor anticipated to be Financially eligible within 180 days of nursing facility admission

Is Individual currently Auxiliary Grant eligible?

0 = No 1 = Yes, or has applied for Auxiliary Grant 2 = No, but is eligible for General Relief Department of Social Services: (Eligibility Responsibility)________________________________ (Services Responsibility)__________________________________

If no, has Individual formally applied for Medicaid?

0 = No 1 = Yes

III. LTSS SCREENING INFORMATION: (to be completed only by authorized Medicaid or ALF screeners) MEDICAID AUTHORIZATION Level of Care 1 = Nursing Facility (NF) Services 2 = PACE 4 = Commonwealth Coordinated Care (CCC) Plus Waiver 11 = ALF Residential Living * (see note below) 12 = ALF Regular Assisted Living * (see note below) 15 = Private Duty Nursing Services provided in the CCC Plus Waiver Exceptions: Authorizations for NF, PACE, CCC Plus Waivers are interchangeable. Screening updates are not required for individuals to move between these services because the alternate institutional placement is a NF. NF = CCC Plus Waiver or PACE.

NO MEDICAID SERVICES AUTHORIZED 8 = Other Services Recommended 9 = Active Treatment for MI, ID or RC 0 = No other services recommended Targeted Case Management for ALF 0 = No 1 = Yes ALF Reassessment Completed 1 = Full Reassessment 2 = Short Reassessment ALF provider name: _____________________________________ ALF admit date: ________________________________________ SERVICE AVAILABILITY 1 = Individual on waiting list for service authorized 2 = Desired service provider not available 3 = Service provider available, services to start immediately

LENGTH OF STAY (If approved for Nursing Facility) 1 = Temporary (less than 3 months ) 2 = Temporary (less than 6 months) 3 = Continuing (more than 6 months) 8 = Not Applicable NOTE: Physicians may write progress notes to address the length of stay for individuals moving between NF, PACE, or CCC Plus Waiver. The progress notes should be provided to the eligibility worker with the local departments of social services.

LTSS/ALF SCREENING IDENTIFICATION Name of LTSS/ALF screener agency and provider number: 1.____________________________________________________

 2.____________________________________________________

 ________________________________________________________________________________________________

LEVEL II ASSESSMENT DETERMINATION – FOR NF AUTHS ONLY – DOES NOT APPLY TO WAIVERS.

Name of Level II Screener and ID number who completed the Level II for a diagnosis of MI, ID, or RC. 1.__________________________________________________

 0= 1= 2= 3=

Did the individual die after the Medicaid LTSS/ALF screening Authorization but before services were received?

1 = Yes 0 = No

Not referred for Level II assessment Referred, Active Treatment needed Referred, Active Treatment not needed Referred, Active Treatment needed but individual chooses NF

SCREENING CERTIFICATION - This authorization is appropriate to adequately meet the Individual's needs and assures that all other resources have been explored prior to Medicaid authorization for this Individual. ________________________________________________________________________________________________ ____/____/________

Medicaid LTSS/ALF Screener

Title

Date

________________________________________________________________________________________________ ____/___/_________

Medicaid LTSS/ALF Screener

Title

Date

________________________________________________________________________________________________ ____/___/_________

Medicaid LTSS Physician DMAS-96 (revised 4/2019)

Date

Instructions for completing the Medicaid Funded Long-Term Services and Supports Authorization (DMAS-96) I. A. B. C. D. E. F. II.

Individual Information: Enter Individual’s Last Name. Required.

Enter Individual’s First Name. Required.

Enter Individual’s Birth Date in MM/DD/CCYY format. Required.

Enter Individual’s Social Security Number. Required.

Enter Individual’s Medicaid ID number if the Individual currently has a Medicaid card. This number should have 12 digits.

Gender: Enter “F” if Individual is Female or “M” if Individual is Male. Required.

Medicaid Eligibility Information: Is Individual Currently Medicaid Eligible?  Enter a “1” in the box if the Individual is currently Medicaid eligible.  Enter a “2” in the box if the Individual is not currently Medicaid eligible but anticipated to be financially eligible within 180 days after nursing facility.  Enter a “3” in the box if the Individual is not eligible for Medicaid and it is not anticipated that private funds will be depleted within 180 days after nursing facility admission.

B. If no, has Individual formally applied for Medicaid? Formal application for Medicaid is made when the Individual or authorized representative has taken the required financial information to the local Eligibility Department and completed forms needed to apply for benefits. The authorization for long-term services and supports can be made regardless of whether the Individual has been determined Medicaid eligible, but placement may not be available until the provider is assured of the Individual’s Medicaid status.

C. Is Individual currently Auxiliary Grant eligible? Enter appropriate code (“0”, “1”, or “2”) in the box.

D. Local Depts. of Social Services: The local departments of social services with service and eligibility responsibility may not always be the same agency. Please indicate, if known, the departments for each in the areas provided.

A.

III. A.

Medicaid LTSS Screening Information: Medicaid Authorization: Enter the numeric code that corresponds to the Medicaid LTSS Screening Level of Care (LOC) authorized. Enter only one code in this box. Required.

1

Nursing Facility (NF)

Authorize only if Individual meets the NF LOC criteria.

2

PACE

Authorize only if Individual meets NF LOC criteria and requires a community-based service to prevent institutionalization.

4

Commonwealth Coordinated Care Plus Waiver

Authorize only if Individual meets NF LOC criteria and requires a community-based service to prevent institutionalization.

11

ALF Residential Living

Authorize only if Individual has dependency in either 1 ADL, 1 IADL or medication administration

12

ALF Regular Assisted Living

Authorize only if Individual has dependency in either 2 ADLs or behavior.

15

Private Duty Nursing Services in CCC Plus Waiver

Authorize only if the Individual meets NF LOC criteria and/or has extensive medical/nursing needs and requires a community-based service to prevent institutionalization.

Exceptions: Authorizations for NF, PACE, or CCC Plus Waiver are interchangeable. Screening updates are not required for Individuals to move between these services because the alternate institutional placement is a NF. NF = CCC Plus Waiver or PACE.

DMAS-96 (revised 4/2019)

Instructions for completing the Medicaid Funded Long-Term Services and Supports Authorization (DMAS-96) B.

C.

D. E. F. G. H.

No Medicaid Services Authorized: Includes informal social support systems or any service excluding Medicaid-funded long 8 Other Services Recommended term services and supports such as companion services, meals on wheels, ID/DD or Day Support waivers, rehab services, etc.).

9

Active Treatment for MI/ID or Related Condition

0

No Other Services Recommended

Applies to those Individuals who meet NF criteria but require active treatment for a condition of mental illness or intellectual/developmental disabilities and cannot appropriately receive such treatment in a NF. Use when the screening team recommends no services or the Individual refuses services.

Targeted Case Management for ALF: If ALF services are authorized; you must indicate whether Targeted Case Management for ALF (quarterly visit) is also being authorized. The Individual must require coordination of multiple services and the ALF or other support must not be available to assist in the coordination/access of these services.

ALF Targeted Case Management Services includes the annual reassessment.

ALF Reassessment: Mark the appropriate code for the long reassessment (“1”) or a short reassessment (“2”).

ALF Provider Name: Enter the name of the ALF in which the Individual entered. Otherwise leave blank.

ALF Admit Date: Enter the date the Individual entered an ALF. Otherwise leave blank.

Service Availability: If a Medicaid-funded long term services and supports is authorized, indicate whether there is a waiting list (”1”) or that there is no provider (“2”), or whether the service can be started immediately (”3”).

Length of Stay: If approval of NF services is made, please indicate how it is felt that these services will be needed by the Individual. The physician’s signature certifies expected length of stay as well as Level of Care.

NOTE: Physicians may write progress notes to address the length of stay for individuals moving between NF, PACE or the CCC Plus Waiver. The progress notes should be provided to the eligibility workers with the local departments of social services.

I. Medicaid LTSS/ALF Screening Identification: Enter the name of the screening agency or facility (for example, hospital, local DSS, local health department, Area Agency on Aging, State MH/IDD facility, CIL) and below it, in the 10 boxes provided, that entity’s 10 digit NPI/API number.

For Medicaid to make prompt payments to LTSS Screening Teams, all of the information in this section must be completed.

Failure to complete any part of this section will delay reimbursement.

If the LTSS Screening is completed in the locality, there should be two screeners, from both the local DSS and local health departments. Otherwise, there will be only one screener identification entered.

J. Level II Assessment Determination: If a Level II assessment was performed (MI, IDD or Related Condition), enter the name of the screener on the top line and below it, in the 10 boxes provided, that entity’s 10 digit NPI/API number. Level II assessments apply to NF authorizations ONLY. Enter the appropriate code in the box.

K. When a Screening Team is aware that an Individual has expired prior to receiving the services authorized by the screening team, a “1” should be entered in this box.

L. The Medicaid LTSS/ALF Screener must sign and date the form. Required.

M. The Medicaid LTSS/ALF Screener must sign and date the form. Required for all services except ALF placement.

N. The Medicaid LTSS physician must sign and date the form. Required for all services except ALF placement. Physician signature and date is the last item to be completed on this form. Physician must sign and date for himself or herself; others may not sign/date for the physician.

IV. Final Items: A.

B.

Once the Medicaid LTSS Screening has been completed, the Screening Team should supply a copy of the Screening Package to the Individual, and the Individual’s provider of choice if the individual is FFS. If the Individual is a CCC Plus member, the Screening Package should be sent to the appropriate Health Plan Care Coordinator.

For adults, the Screening Team must maintain a complete copy of the Medicaid LTSS Screening in their files for a period of not less than 6 years from the date of screening. For children, Screening teams must retain documents for at least six (6) years after such minors have reached 21 years of age. Files may be in either paper or electronic format.

*NOTE: DMAS does not require the submission of ALF Screening documents. Screening Teams are required to follow all regulations with respect to completion of the documents for ALF services. The Screening Teams should follow instructions provided regarding reimbursement for ALF screenings.

DMAS-96 (revised 04/2019)

Individual Name:

Medicaid LTC Communication Form

Medicaid ID#:

Provider Name:

Address:

Provider NPI#: Telephone:

Provider Rep.:

Title:

Fax:

Patient Information:

SSN:

Date:

DMAS-96

attached

/

/

from

unavailable

Individual admitted to this facility/service on

/

Home

Hospital

Patient Pay determination requested

Patient Funds Account balance $

as of

Individual discharged

/

/

(date),

to:

/

(date),

Home

Hospital

Other Facility

Change in income, deductions, health insurance or other:

Other Facility /

/

(date).

Deceased

RUGS Score __________ (NF individuals only)

*Individual Residential Address: Medicaid Per Diem Rate:

$

*Enrollee FIPS:

CBC Provider Hourly Rate: $

(Waiver Individuals Only)

Hours received in the month of Discharge:

If discharging from services, please include all Service Authorization #(s):

LDSS:

FIPS Code:

Telephone:

Fax :

Eligibility Worker: Date:

/

/

Eligibility Information:

Eligible, full Medicaid services beginning

/

/

Eligible, QMB Medicaid only

(date)

Eligible Medicare premium payment only Ineligible for Medicaid Medicare Part A insurance

Ineligible for Medicaid payment of LTC services from Other health insurance:

/

/

to

/

/

LTC insurance:

Change in deductions, health insurance or other: Department of Medical Assistance

DMAS-225 Revised 12/15

Medicaid LTC Communication Form

DMAS-225

PURPOSE OF FORM--To allow the local Department of Social Services (LDSS) and nursing facility (NF) or Community Based Care (CBC) Waiver Providers to exchange information regarding: o o o o

The Medicaid eligibility status of an individual; A change in the individual’s level of care; Admission or discharge of an individual to an institution or Medicaid CBC services, or death of an individual; Other information known to the provider that might cause a change in the eligibility status or patient pay amounts.

USE OF FORM--Initiated by either the LDSS or the provider of care. A new form must be prepared by the LDSS whenever there is any change in the individual’s circumstances that results in a change in eligibility status or information needs to be given to the provider. The provider must use the form to document admission date, request Medicaid eligibility status, and notify the LDSS of changes in the individual’s circumstances, discharge or death.

NUMBER OF COPIES--Original and one copy for NF individuals; original and two copies for waiver individuals.

DISTRIBUTION OF COPIES--For NF individuals, send the original to the nursing facility. For PACE individuals send the original to the PACE provider. For Medicaid CBC, send the original to the following individuals: • Case Manager at DMAS for Tech Waiver, DMAS, Division of LTC, Waiver Unit, 600 E. Broad St., Richmond, VA 23219 • Case Manager at the Community Service Board for the ID and DS waivers • Case Manager (Support Coordinator) at DBHDS for DD Waiver • Service Facilitator for EDCD with consumer-directed service, • Case Manager for any individual w/case management services which includes those receiving services through CCC or other managed Medicaid plans, and • Personal Care Provider for EDCD-personal care services and other services.

Place a copy of this form in the eligibility case file.

INSTRUCTIONS FOR PREPARATION OF THE FORM--Complete either the Provider or LDSS section as appropriate. At the top of the form, enter the Individual’s name, Social Security number and Medicaid identification number, if known.

Provider Section-Complete all data elements in the gray section. Check the appropriate boxes and complete all data elements as appropriate in the white section to the individual’s circumstances. Providers should attach a copy of the DMAS-96 to this form when the individual is first admitted to care.

Waiver providers must advise the LDSS of the individual residential address when different from the address from which this form originates and provide the individual FIPS code.

Providers should ensure that the individual understands that they may have a patient pay, which is the amount of their income that must be paid to the provider every month for the cost of long-term care services they receive. The long-term care provider who is responsible for collection of any portion of the patient pay will directly bill the individual or your representative. A portion of patient pay may be paid to more than one provider when services are received from multiple providers.

LDSS Section-Complete all data elements of the gray section. Check the appropriate boxes and complete all data elements in the white section as appropriate to the individual’s circumstances. Do not provide the source of an individual’s income. If the individual is ineligible for Medicaid payment of long-term care due to imposition of a penalty period, send a copy of this memo to the DMAS, Long-Term Care Division, 600 E. Broad St., Suite 1300, Richmond, Va. 23219 Department of Medical Assistance

DMAS-225 Revised 12/15

LEVEL I SCREENING FOR MENTAL ILLNESS, INTELLECTUAL DISABILITY, OR RELATED CONDITIONS This form, or the DMAS-95 for Medicaid members, must be completed for ALL individuals seeking a Nursing Facility admission.

The form must be completed PRIOR to a Nursing Facility admission by the Staff assigned to conduct Level I Screening.

Name: Date of Birth: If Applicable Social Security No. Medicaid No. 1.

DOES THE INDIVIDUAL MEET NURSING FACILITY CRITERIA?

 Yes  No

(If NO, the individual should not be admitted to a NF nor be referred for a Level II Screening.)

Can a safe and appropriate plan of care be developed to meet all services and supports including medical/nursing/custodial care needs?

a.

 Yes  No

If the answer to #1 is “Yes”, the remainder of this form MUST BE COMPLETED. 2.

DOES THE INDIVIDUAL HAVE A CURRENT SERIOUS MENTAL ILLNESS (MI)?  Yes  No (Check “Yes” only if each item below are all “Yes”. If “No”, do not refer for evaluation of active treatment needs for MI Diagnosis.) a. Is this major mental disorder diagnosable under DSM (e.g., schizophrenia, mood, paranoid, panic, or other serious anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or other mental disorder that may lead to a chronic disability)?

 Yes  No b.

Has the disorder resulted in functional limitations in major life activities within the past 3-6 months, particularly with regard to

c.

interpersonal functioning; concentration, persistence, or pace; and adaptation to change?  Yes  No Does the treatment history indicate that the individual has experienced psychiatric treatment more intensive than outpatient care more than once in the past 2 years or the individual has experienced within the last 2 years an episode of significant disruption to the normal living situation due to the mental disorder?

3.

DOES THE INDIVIDUAL HAVE A DIAGNOSIS OF INTELLECTUAL DEVELOPMENTAL DISABILITY (IDD) WHICH WAS MANIFESTED BEFORE AGE 18?

4.

 Yes  No

DOES THE INDIVIDUAL HAVE A RELATED CONDITION (RC)?  Yes  No (Check “Yes” only if each item below is checked “Yes”. If “No”, do not refer for evaluation of active treatment needs for related condition.) a. Is the condition attributable to any other condition (e.g. cerebral palsy, epilepsy, autism, muscular dystrophy, multiple sclerosis, Frederick’s ataxia, spina befida), other than MI, found to be closely related to ID because this condition may result in impairment of general intellectual functioning or adaptive behavior similar to that of ID persons and requires treatment of services similar to those for these persons? b. c. d.

5.

 Yes  No

 Yes  No

 Yes  No Is the condition likely to continue indefinitely?  Yes  No Has the condition manifested before age 22?

Has the condition resulted in substantial limitations in three (3) or more of the following areas of major life activity; self-care understanding and use of language, learning, mobility, self-direction, and capacity for independent living?

 Yes (If yes, circle applicable areas)  No RECOMMENDATION (Either “a” or “b” must be checked.) a.  Refer for Level II evaluation.

DATE LEVEL II REFERRAL MADE

(NF Placement = Level II refer to Ascend Maximus Management)

  

MI (# 2 above is checked “Yes”) ID or Related Condition (# 3 or # 4 is checked “Yes”)

Dual diagnosis (MI and IDD or Related Condition categories are checked) ** NOTE: If 5a is checked, the individual may NOT be authorized for Medicaid-funded NF LTSS until the Level II evaluation has been completed. b.  No referral for Level II evaluation for active treatment needs required because individual:

   

Does not meet the applicable criteria for serious MI or ID or related condition Has a primary diagnosis of dementia (including Alzheimer’s disease) and does not have a diagnosis of ID Has a primary diagnosis of dementia (including Alzheimer’s disease) AND has a secondary diagnosis of a serious MI Has a severe physical illness (e.g. documented evidence of coma, functioning at brain-stern level, or other conditions which results in a level of impairment so severe that the individual could not be expected to benefit from specialized services.)

 Is terminally ill (note: a physician must have documented that individual’s life expectancy is six (6) months or less)

Signature & Title: DMAS-95, Level I PASRR Form, Revised 4/2019

Date:

Telephone #:

Street Address:

LEVEL I SCREENING FOR MENTAL ILLNESS, INTELLECTUAL DISABILITY, OR RELATED CONDITIONS INSTRUCTIONS FOR COMPLETION NAME: Enter the Individual’s Full Name SOCIAL SECURITY NUMBER: REQUEST RECEIVED:

Enter the 9-digit number

DATE OF BIRTH: MM/DD/YYYY IF APPLICABLE THE MEDICAID NUMBER: Enter the 12-digit number

Enter the date that a request for a Level II evaluation was made

1.

Nursing Facility Level of Care: Indicate whether the individual meets nursing facility level of care criteria. For reference, level of care criteria can be found in the Medicaid Long-Term Services and Supports Manual Chapter IV found on the Virginia Medicaid portal.

If “yes” is checked, complete the screening.

If “no”, is checked, the individual does NOT meet nursing facility level of care criteria, do not complete the Level I screening and do not refer for a Level II evaluation.

2.

Determination of Serious Mental Illness (MI): Check “yes” (that the individual has a current diagnosis of serious MI) only if each item in 2- a, b and c is checked “yes”. Indicate the diagnosis if “yes’ is checked. If any answer to a, b or c is “no”, then “no” is checked for the overall question and do not refer for Level II evaluation for mental illness. a.

Check “yes’ if the individual has a major mental disorder diagnosable under DSM (eg, schizophrenia (including disorganized, catatonic, and paranoid types), mood (including bipolar disorder (mixed depressed, seasonal, or NOS)). Major depression (single episode/recurrent, chronic, melancholic or seasonal), depressive disorder NOS, cyclothymia, dysthymia (primary/secondary or early/late onset). Paranoid (including delusional, erotomanic, grandiose, jealous, persecutory, somatic, unspecified, or induced psychotic disorder), panic or other severe anxiety disorder (including panic disorder with agoraphobia. agoraphobia with or without history of panic disorder, social anxiety disorder, obsessive compulsive disorder, posttraumatic stress disorder), somatoform disorder (includes somatization disorder, conversion disorder somatoform pain disorder, hypochondriasis. body dysmorphic disorder, undifferentiated somatotorm disorder, somatoform disorder NOS). Personality disorder (includes paranoid. schizoid. sehizotypal. histrionic, narcissistic, antisocial, borderline. avoidant, dependent. obsessive compulsive, passive aggressive, and NOS), other psychotic disorder (includes schizophreniform disorder. schizoaffective disorder (bipolar/depressive), brief reactive psychosis, atypical NOS or other mental disorder that may lead to a chronic disability). b. Check “yes” if the individual has a mental disorder that has resulted in functional limitations in major life activities within the past 3-6 months, particularly with regard to interpersonal functioning concentration, persistence, pace and adaptation to change c. Check “yes’ if the individual’s treatment history indicates that he or she has experienced (1) psychiatric treatment more intense than outpatient care more than once in the past 2 years or (2) within the last 2 years, an episode of significant disruption to the normal living situation due to the mental disorder

3.

Determination of Intellectual Disability ID: Check “yes’ if the individual has a level of intellectual disability (mild, moderate, severe, or profound) described in the Classification in Mental Retardation: Chapter 3. American Association on Mental Deficiency (AAMD), 1983 that was manifested before age 18. Please note this reference is specifically cited in the Code of Federal Regulations but the AAMD is now known as the American Association on Intellectual and Developmental Disabilities (AAIDD) and the term Mental Retardation is no longer standardly used and has been replaced with Intellectual Disability.

4.

Determination of Related Conditions: Check ‘yes’ for answer for 4, only if each item in 4, a-d is checked “yes”. If any answer to a-d is “no”, then “no” is checked for the overall question and do not refer for Level II evaluation for related conditions. a.

Check ‘yes’ if the condition is attributable to any other condition (e g, cerebral palsy, epilepsy, autism, muscular dystrophy, multiple sclerosis, Frederick’s ataxia, spina bifida), other than MI, found to be closely related to intellectual disability because this condition may result in impairment of general intellectual functioning or adaptive behavior similar to that of persons living with ID and requires treatment or services similar to those for persons living with ID. b.

Check ‘yes” if the condition has manifested before age 22 c.

Cheek “yes” if the condition is likely to continue indefinitely d.

Check “yes’ if the condition has resulted in substantial limitations in three (3) or more of the following areas of major life activity: self-care, understanding, use of language, learning, mobility, self-direction, and capacity for independent living. Circle the applicable areas.

5.

RECOMMENDATION (Either 5a or b MUST be checked) a. Check this category if Question 2 is checked ‘yes’ AND/OR either Question 3 or 4 is checked “yes”. Indicate whether referral is for MI, ID or RC, the date the package is referred to the appropriate Level II evaluator, and where and to whom the package is sent. An individual for whom 5a has been checked may NOT he admitted to a LTSS until the secondary evaluation is completed. b. Check this “no referral needed” category ONLY if there is documented evidence as follows • Does not meet the ‘applicable criteria For MI, ID or a related condition.

• Has a primary diagnosis of dementia (including Alzheimer’s disease), If there is a diagnosis of ID this category does not apply.

• Has a primary diagnosis of dementia (including Alzheimer’s disease) AND a secondary diagnosis of MI. • Has a severe physical illness (e.g. documented evidence of coma, functioning at brain-stem level, or other diagnoses, which results in a level of impairment so severe that the individual could not be expected to benefit from specialized services. If the answer determines that an illness not listed here is so severe that the individual could not be expected to benefit from specialized services, documentation describing the severe illness must be attached for review).

• Is terminally ill (note: a physician must document that individual’s life expectancy is less than 6 months).

NOTE: WHEN A LEVEL I SCREENING HAS NOT BEEN PERFORMED PRIOR TO AN INDIVIDUAL’S ADMISSION TO A NF FEDERAL FINANCIAL PARTICIPATION (FFP) WILL NOT BE AVAILABLE UNTIL A SCREENING IS COMPLETE. SCREENER INFORMATION SIGNATURE: DMAS-95, Level I PASRR Form, Revised 4/2019

First Name, Middle initial, and Last Name

TITLE: SCREENING ENTITY: DATE: TELEPHONE NUMBER: STREET ADDRESS:

DMAS-95, Level I PASRR Form, Revised 4/2019

Professional title of the screener Name of entity (organization) which performed the screening Date screening was completed Telephone number, including area code Complete Street address, including city-state and zip code

VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES MI/IDD/Related Conditions SUPPLEMENT: LEVEL II Name: ________________________________________________________ Recommendation for Services _________________________

B. This section is to be completed by the contractor for the Level II evaluation process.

1.

EVALUATIONS REQUIRED UPON RECEIPT OF REFERRAL (Check evaluations submitted upon receipt of referral) _____ _____ _____

2.

Neurological Evaluation Psychological Assessment Psychiatric Assessment

_____ _____

_____

Psychosocial/Functional Assessment History and Physical Examination Other (please specify)______________________________

RECOMMENDATION _____

Specialized services are not indicated.

______

Specialized services are indicated.

Comments:_________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________

3 .Date referral package received: _______________________

Date package sent to DBHDS: ___________________________________

QMHP Signature (MI diagnosis)

Date

Telephone Number

Psychologist Signature (IDD diagnosis)

Date

Telephone Number

Case Manager Signature/Title

Date

Telephone Number

Agency / Facility Name

Agency / Facility Name ID # ( if applicable)

Mailing Address

C. THIS SECTION IS TO BE COMPLETED ONLY BY THE DEPARTMENT OF BEHAVORIAL HEALTH AND DEVELOPMENTAL SERVICES. Date referral package received:___________________________________ Concur with recommendations of specialized services? ____ yes ____ no Comments: __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ Copies of referral package sent to: _____ PAS representative _____ Community Services Board ______ Admitting/retaining nursing facility ___ Discharging hospital (if applicable) _______ Individual being evaluated ______ Individual’s family _____ Individual’s legal representative (if any) ______ Attending physician Appeals information included.

Signature of State MH/MRA DMAS-95

MI/IDD/RC Supplement (Revised 12/15)

Representatives Name

Title

Date

Date Package Sent

Telephone Number

Department of Health and Human Services Centers for Medicare & Medicaid Services

Form Approved OMB No. 0938-0357

HOME HEALTH CERTIFICATION AND PLAN OF CARE 1. Patient’s HI Claim No.

2. Start Of Care Date

3. Certification Period From:

M

Principal Diagnosis

9. Sex

Date

12. ICD

Surgical Procedure

Date

13. ICD

Other Pertinent Diagnoses

Date

F

10. Medications: Dose/Frequency/Route (N)ew (C)hanged

14. DME and Supplies

15. Safety Measures

16. Nutritional Req. 18.A. Functional Limitations

17. Allergies 18.B. Activities Permitted

1

Amputation

5

Paralysis

2

Bowel/Bladder (Incontinance)

6

Endurance

3

Contracture

7

Ambulation

4

Hearing

8

Speech

19. Mental Status 20. Prognosis

9 A B

5. Provider No.

To: 7. Provider’s Name, Address and Telephone Number

6. Patient’s Name and Address

8. Date of Birth 11. ICD

4. Medical Record No.

Legally Blind

1

Complete Bedrest

6

Partial Weight Bearing

A

Wheelchair

Dyspnea With Minimal Exertion Other (Specify)

2

Bedrest BRP

7

Independent At Home

B

Walker

3

Up As Tolerated

8

Crutches

C

No Restrictions

4

Transfer Bed/Chair

9

Cane

D

Other (Specify)

5

Exercises Prescribed

5

Excellent

1

Oriented

3

Forgetful

5

Disoriented

7

Agitated

2

Comatose

4

Depressed

6

Lethargic

8

Other

1

Poor

2

Guarded

3

Fair

4

Good

21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)

22. Goals/Rehabilitation Potential/Discharge Plans

23. Nurse’s Signature and Date of Verbal SOC Where Applicable:

25. Date of HHA Received Signed POT

24. Physician’s Name and Address

26. I certify/recertify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need occupational therapy. The patient is under my care, and I have authorized services on this plan of care and will periodically review the plan.

27. Attending Physician’s Signature and Date Signed

28. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds may be subject to fine, imprisonment, or civil penalty under applicable Federal laws.

Form CMS-485 (C-3) (12-14) (Formerly HCFA-485) (Print Aligned)

Privacy Act Statement Sections 1812, 1814, 1815, 1816, 1861 and 1862 of the Social Security Act authorize collection of this information. The primary use of this information is to process and pay Medicare benefits to or on behalf of eligible individuals. Disclosure of this information may be made to: Peer Review Organizations and Quality Review Organizations in connection with their review of claims, or in connection with studies or other review activities, conducted pursuant to Part B of Title XI of the Social Security Act; State Licensing Boards for review of unethical practices or nonprofessional conduct; A congressional office from the record of an individual in response to an inquiry from the congressional office at the request of that individual.

Where the individualâ&#x20AC;&#x2122;s identification number is his/her Social Security Number (SSN), collection of this information is authorized by Executive Order 9397. Furnishing the information on this form, including the SSN, is voluntary, but failure to do so may result in disapproval of the request for payment of Medicare benefits.

Paper Work Burden Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0357. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Mailstop N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Department of Health and Human Services Centers for Medicare & Medicaid Services

Form Approved OMB No. 0938-0357

HOME HEALTH CERTIFICATION AND PLAN OF CARE 1. Patient's HI Claim No.

2. Start Of Care Date

3. Certification Period From:

9. Sex

M

F

10. Medications: Dose/Frequency/Route (N)ew (C)hanged

Date

12. ICD-9-CM Surgical Procedure

Date

13. ICD-9-CM Other Pertinent Diagnoses

Date

14. DME and Supplies

15. Safety Measures:

16. Nutritional Req.

17. Allergies: 18.B. Activities Permitted

18.A. Functional Limitations Amputation 1 Bowel/Bladder (Incontinence) 2 3

Contracture

4

Hearing

19. Mental Status:

5. Provider No.

To: 7. Provider's Name, Address and Telephone Number

6. Patient's Name and Address

8. Date of Birth 11. ICD-9-CM Principal Diagnosis

4. Medical Record No.

Paralysis

5 6

Endurance

7

Ambulation

8

Speech

1

Oriented

2

Comatose

9

Legally Blind

1

Complete Bedrest

A B

Dyspnea With Minimal Exertion Other (Specify)

2

Bedrest BRP

6 7

Independent At Home

A B

3

Up As Tolerated

8

Crutches

C

No Restrictions

4 5 5

Transfer Bed/Chair

9

Cane

D

Other (Specify)

7 8 4

Other

5

Excellent

3

Forgetful Depressed

4 1 Poor 2 20. Prognosis: Guarded 21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)

6 3

Partial Weight Bearing

Wheelchair Walker

Exercises Prescribed Disoriented Lethargic

Fair

Agitated

Good

22. Goals/Rehabilitation Potential/Discharge Plans

23. Nurse's Signature and Date of Verbal SOC Where Applicable:

25. Date HHA Received Signed POT

24. Physician's Name and Address

26. I certify/recertify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need occupational therapy. The patient is under my care, and I have authorized the services on this plan of care and will periodically review the plan.

27. Attending Physician's Signature and Date Signed

28. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds may be subject to fine, imprisonment, or civil penalty under applicable Federal laws.

Form CMS-485 (C-3) (02-94) (Formerly HCFA-485) (Print Aligned)

Privacy Act Statement Sections 1812, 1814, 1815, 1816, 1861, and 1862 of the Social Security Act authorize collection of this information. The primary use of this information is to process and pay Medicare benefits to or on behalf of eligible individuals. Disclosure of this information may be made to : Peer Review Organizations and Quality Review Organizations in connection with their review of claims, or in connection with studies or other review activities, conducted pursuant to Part B of Title XI of the Social Security Act; State Licensing Boards for review of unethical practices or nonprofessional conduct; A congressional office from the record of an individual in response to an inquiry from the congressional office at the request of that individual.

Where the individual's identification number is his/her Social Security Number (SSN), collection of this information is authorized by Executive Order 9397. Furnishing the information on this form, including the SSN, is voluntary, but failure to do so may result in disapproval of the request for payment of Medicare benefits.

Paper Work Burden Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0357. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Mailstop N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

AGENCY OR CONSUMER DIRECTION PROVIDER PLAN OF CARE Agency-Directed Services

Consumer-Directed Services

Participant: Provider:

1.

Categories/Tasks ADL’s

Monday

Tuesday

Wednesday

Current DMAS-99 Date: __________ Medicaid ID#: Provider ID#:

Thursday

Friday

Saturday

Sunday

Bathing Dressing Toileting Transfer Assist Eating Assist Ambulate Turn/Change Position Grooming Total ADL Time: 2.

Special Maintenance Vital Signs Supervise Meds *Range of Motion *Wound Care *Bowel/Bladder Program *MD order required Total Maint. Time: 3.

Supervision Time 4.

IADLS Meal Preparation Clean Kitchen Make/Change Beds Clean Areas Used by Participant Shop/List Supplies Laundry (CD only) Money Management Medical Appointments Work/School/Social Total IADLS Time: TOTAL DAILY TIME: This Section Must Be Completed in its Entirety for Agency & Consumer-Directed Services Composite ADL Score = (The sum of the ADL ratings that describe this participant) BATHING SCORE Bathes without help or with MH only 0 Bathes with HH or with HH & MH 1 Is bathed 2 DRESSING SCORE Dress without help or with MH only 0 Dresses with HH or with HH & MH 1 Is dressed or does not dress 2 AMBULATION SCORE Walks/Wheels without help w/MH only 0 Walks/Wheels w/ HH or HH & MH 1 Totally dependent for mobility 2

LEVEL OF CARE  A (Score 0 - 6) (LOC) Maximum Hours of 25/Week Page 1 of 2

- DMAS-97A/B - Revised 04/2019

TRANSFERRING SCORE Transfers without help or with MH only Transfers w/ HH or w/HH & MH Is transferred or does not transfer EATING SCORE Eats without help or with MH only Eats with HH or HH & MH Is fed: spoon/tube/etc.

CONTINENCY SCORE Continent/incontinent < wkly self care of internal /external devices Incontinent weekly or > Not self care



B (Score 7 - 12)

Maximum Hours 30/Week

0 1 2 0 1 2

0 2

 C (Score 9 + wounds, tube feedings, etc.)

Maximum Hours 35/Week

Participant Provider:

Medicaid ID#: Provider ID#:

Initial Plan of Care hours must be pre-authorized & should not exceed the maximum for the specified LOC category.

Documentation must support the amount of hours provided to the participant.

Reason Plan of Care Submitted:



New Admission

 ↑ In Hours

 ↓ In Hours



Transfer

Reason for change/additional instructions for the aide:

Required Backup Plan (Person’s name, relation and phone #) for Services: Plan of Care Effective Date:

Total Weekly Hours:

Participant / Primary Caregiver Signature:

Date:

RN, LPN or SF Signature

Date:

Instructions for the DMAS-97A/B Provider Notification to Participant This Plan of Care has been revised based on your current needs and available support. If you agree with the changes, no action is required on your part. If you do not agree with the changes, please contact the RN Supervisor who has signed the plan of care to discuss the reason that you disagree with the change.

If the provider agency is unwilling or unable to change the information, and you still disagree, you have the right to an appeal by notifying, in writing, The Client Appeals Division, The Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, Virginia 23219. The request for an appeal must be filed within thirty (30) days of the time you receive this notification. If you file a request for an appeal before the effective date of this action, ____________ (enter effective date), services may continue unchanged during the appeal process.

Category/Tasks Place a check mark for each task and put the total time for each category, for each day. Writing the amount of time for each task to the nearest 15 minutes is not necessary, but it greatly assists in the review of authorization requests.

Level of Care Determination for Maximum Weekly Hours Enter a score for each activity of daily living (ADL) based on the participant’s current functioning. Sum each ADL rating & enter the composite score under the appropriate category: A, B, or C. The amount of time allocated under TOTAL DAILY TIME to complete all tasks MUST NOT EXCEED the maximum weekly hours for the specified LOC of A, B, or C. Service Authorization (SA) must be obtained prior to initiating a change outside the authorized LOC category.

Provider Notification to Participant Any time the RN Supervisor or Services Facilitator (SF) changes the plan of care that results in a change in the total number of weekly hours, the RN or SF must complete the entire front section of this form. If the change the agency is making does not require SA approval, the RN Supervisor or SF is required to enter the effective date on the Provider Agency Participant Notification Section which gives the participant their right to appeal. The participant should get a copy of both the front and back of the form.

SA Contractor Notification to Participant If the changes to the Plan of Care require SA approval, the entire front portion of this form and the DMAS-98 must be completed and forwarded to the SA contractor for approval. If supervision is requested, attach the Request for Supervision form (DMAS-100). Once received by the SA contractor, the SA analyst will review the care plan and indicate whether the request is pended, approved, or denied. The participant will receive by mail the decision letter from the SA Contractor.

Participant / Caregiver Signature The participant’s signature is necessary on the original plan of care and decreases to the hours of care. It is not needed if the hours increase in a new plan of care. The provider may substitute the signature with documentation in the participant’s record that shows acceptance of the plan of care.

Page 2 of 2

- DMAS-97A/B - Revised 04/2019

AGENCY OR CONSUMER DIRECTION PROVIDER PLAN OF CARE Agency-Directed Services

Consumer-Directed Services

Participant: Provider:

1.

Categories/Tasks ADL’s

Monday

Tuesday

Wednesday

Current DMAS-99 Date: __________ Medicaid ID#: Provider ID#:

Thursday

Friday

Saturday

Sunday

Bathing Dressing Toileting Transfer Assist Eating Assist Ambulate Turn/Change Position Grooming Total ADL Time: 2.

Special Maintenance Vital Signs Supervise Meds *Range of Motion *Wound Care *Bowel/Bladder Program *MD order required Total Maint. Time: 3.

Supervision Time 4.

IADLS Meal Preparation Clean Kitchen Make/Change Beds Clean Areas Used by Participant Shop/List Supplies Laundry (CD only) Money Management Medical Appointments Work/School/Social Total IADLS Time: TOTAL DAILY TIME: This Section Must Be Completed in its Entirety for Agency & Consumer-Directed Services Composite ADL Score = (The sum of the ADL ratings that describe this participant) BATHING SCORE Bathes without help or with MH only 0 Bathes with HH or with HH & MH 1 Is bathed 2 DRESSING SCORE Dress without help or with MH only 0 Dresses with HH or with HH & MH 1 Is dressed or does not dress 2 AMBULATION SCORE Walks/Wheels without help w/MH only 0 Walks/Wheels w/ HH or HH & MH 1 Totally dependent for mobility 2

LEVEL OF CARE  A (Score 0 - 6) (LOC) Maximum Hours of 25/Week Page 1 of 2

- DMAS-97A/B - Revised 04/2019

TRANSFERRING SCORE Transfers without help or with MH only Transfers w/ HH or w/HH & MH Is transferred or does not transfer EATING SCORE Eats without help or with MH only Eats with HH or HH & MH Is fed: spoon/tube/etc.

CONTINENCY SCORE Continent/incontinent < wkly self care of internal /external devices Incontinent weekly or > Not self care



B (Score 7 - 12)

Maximum Hours 30/Week

0 1 2 0 1 2

0 2

 C (Score 9 + wounds, tube feedings, etc.)

Maximum Hours 35/Week

Participant Provider:

Medicaid ID#: Provider ID#:

Initial Plan of Care hours must be pre-authorized & should not exceed the maximum for the specified LOC category.

Documentation must support the amount of hours provided to the participant.

Reason Plan of Care Submitted:



New Admission

 ↑ In Hours

 ↓ In Hours



Transfer

Reason for change/additional instructions for the aide:

Required Backup Plan (Person’s name, relation and phone #) for Services: Plan of Care Effective Date:

Total Weekly Hours:

Participant / Primary Caregiver Signature:

Date:

RN, LPN or SF Signature

Date:

Instructions for the DMAS-97A/B Provider Notification to Participant This Plan of Care has been revised based on your current needs and available support. If you agree with the changes, no action is required on your part. If you do not agree with the changes, please contact the RN Supervisor who has signed the plan of care to discuss the reason that you disagree with the change.

If the provider agency is unwilling or unable to change the information, and you still disagree, you have the right to an appeal by notifying, in writing, The Client Appeals Division, The Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, Virginia 23219. The request for an appeal must be filed within thirty (30) days of the time you receive this notification. If you file a request for an appeal before the effective date of this action, ____________ (enter effective date), services may continue unchanged during the appeal process.

Category/Tasks Place a check mark for each task and put the total time for each category, for each day. Writing the amount of time for each task to the nearest 15 minutes is not necessary, but it greatly assists in the review of authorization requests.

Level of Care Determination for Maximum Weekly Hours Enter a score for each activity of daily living (ADL) based on the participant’s current functioning. Sum each ADL rating & enter the composite score under the appropriate category: A, B, or C. The amount of time allocated under TOTAL DAILY TIME to complete all tasks MUST NOT EXCEED the maximum weekly hours for the specified LOC of A, B, or C. Service Authorization (SA) must be obtained prior to initiating a change outside the authorized LOC category.

Provider Notification to Participant Any time the RN Supervisor or Services Facilitator (SF) changes the plan of care that results in a change in the total number of weekly hours, the RN or SF must complete the entire front section of this form. If the change the agency is making does not require SA approval, the RN Supervisor or SF is required to enter the effective date on the Provider Agency Participant Notification Section which gives the participant their right to appeal. The participant should get a copy of both the front and back of the form.

SA Contractor Notification to Participant If the changes to the Plan of Care require SA approval, the entire front portion of this form and the DMAS-98 must be completed and forwarded to the SA contractor for approval. If supervision is requested, attach the Request for Supervision form (DMAS-100). Once received by the SA contractor, the SA analyst will review the care plan and indicate whether the request is pended, approved, or denied. The participant will receive by mail the decision letter from the SA Contractor.

Participant / Caregiver Signature The participant’s signature is necessary on the original plan of care and decreases to the hours of care. It is not needed if the hours increase in a new plan of care. The provider may substitute the signature with documentation in the participant’s record that shows acceptance of the plan of care.

Page 2 of 2

- DMAS-97A/B - Revised 04/2019