alzheimer's waiver documentation requirements

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


Alzheimer's Waiver Documentation Requirements



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


http://dmasva.dmas.virginia.gov



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



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.



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.



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.



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.



Today’s Training Objectives• Waiver overview and revised regulationsTo review the Alzheimer Waiver Criteria• To review documentation requirements for






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.



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.



Today’s Training Objectives• Waiver overview and revised regulations• To review the Alzheimer Waiver CriteriaTo review documentation requirements for






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.



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



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



Uniform Assessment InstrumentHelpful Hint:Make sure screening dateis in top right hand cornerBe sure a medical/nursing need is indicated on page 7



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



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.



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



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

https://dmas.depro.org/



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





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.



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



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



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





documentation/forms To review quality management review




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



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.



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.



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.



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



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)



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



QMR Documentation Requirements• Individual summaries (DMAS 483)

completed by the LHCP.– The annual summaries

and– Monthly summaries



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”



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.



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.



DMAS 483DMAS 483 - AAL Waiver Admission Summary & Monthly Summary Page 2

Helpful Hints:• Monitor existence of prohibiting

conditions• Medical/Nursing needs



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






documentation requirementsTo discuss discharge from the waiver• Question and Answer



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



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



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.






documentation requirements• To discuss discharge from the waiverQuestion and Answer



Provider Call CenterClaims, covered services, billing

inquiries:

800-552-8627 804-786-6273

8:30am – 4:30pm (Monday-Friday)11:00am – 4:30pm (Wednesday)



Department of Medical Assistance ServicesLong Term Care DivisionTelephone number – 804-225-4222Fax number- 804-612-0040Web portal-

www.virginiamedicaid.dmas.virginia.gov

alzheimer's waiver documentation requirements

Documents

dss regulations 22vac40

staffing requirements

current aal waiver changes

family caregivers http

direct care staffing

specialty care unit

revised regulationsto

recipients admission