Alzheimer's Waiver Documentation Requirements

1. Department of Medical Assistance Services Alzheimer's Waiver Documentation Requirements Department of Medical Assistance Services Division of Long-Term Care 2013 revisions http://dmasva.dmas.virginia.gov 1

2. Department of Medical Assistance Services Today’sTraining Objectives • Waiver overview and revised regulations • To review the Alzheimer Waiver Criteria • To review documentation requirements for recipients' admission into the waiver • To review additional required documentation/forms • To review quality management review documentation requirements • To discuss discharge from the waiver • Question and Answer http://dmasva.dmas.virginia.gov 2

3. 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

4. Revised Regulations • Revised regulations for the AAL Waiver was signed by the Governor and became effective 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.

5. 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.

6. 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.

7. Revised Regulations • Details concerning all the current AAL Waiver changes and additions can be found in: 12VAC30-120-1600 through 12VAC30-120-1660 Adding 12VAC30-120-1605, 12VAC30-120- 1670,12VAC30-120-1680.

8. Today’sTraining 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

9. Qualifying Criteria Individuals 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.

10. Qualifying Criteria • 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.

11. 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

12. 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.

13. Alzheimer's Assisted Living WaiverPreauthorization Process The 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 Physical 4. Documentation of Alzheimer’s diagnosis – DMAS 415 5. Verification of Auxiliary Grant Status 6. DMAS 480

14. DMAS 480 Alzheimer’s Assisted Living Authorization Request Helpful Hint: Must be signed, dated Be sure to include Medicaid number and the correct Atypical Provider Identifier

15. Uniform Assessment Instrument Helpful Hint: Make sure screening date is in top right hand corner Be sure a medical/nursing need is indicated on page 7

16. 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 waiver Make sure it is signed by, RN, MD, and SW

17. 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.

18. DSS 032-05-007/8 Helpful Hint: • Please submit the most recent exam with your admission packet • Carefully review the list of prohibitive conditions • Recipient name should be on each page of document • Make sure it is signed by facility representative

19. 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.org Phone: 1-888-827-2884 OR FAX to 1-887-652-9329

20. 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

21. 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.

22. DMAS 99C Level of Care Review Instrument Helpful 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

23. DMAS 99C Level of Care Review Instrument Page 2 Helpful Hints: • Some sections may not apply • Make sure there is current medical record documentation to support Alzheimer's Diagnosis

24. 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

25. 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

26. 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

27. 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.

28. 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.

29. 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.

30. 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

31. ISP – Example of Measurable Goals

32. 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

33. QMR Documentation Requirements • Individual summaries (DMAS 483) completed by the LHCP. • The annual summaries and • Monthly summaries

34. DMAS 483 DMAS 483 - AAL Waiver Admission Summary & Monthly Summary • Helpful Hint: • Make sure recipients name is on each page • Circle “Admission Summary” or “Monthly Summary”

35. 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.

36. 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.

37. DMAS 483 DMAS 483 - AAL Waiver Admission Summary & Monthly Summary Page 2 • Helpful Hints: • Monitor existence of prohibiting conditions • Medical/Nursing needs

38. DMAS 483 DMAS 483 - AAL Waiver Admission Summary & Monthly Summary Page 3 • 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

39. 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

40. 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

41. 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

42. 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.

43. 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

44. Provider Call Center Claims, covered services, billing inquiries: 800-552-8627 804-786-6273 8:30am – 4:30pm (Monday-Friday) 11:00am – 4:30pm (Wednesday)

45. Department of Medical Assistance Services Long Term Care Division Telephone number – 804-225-4222 Fax number- 804-612-0040 Web portal- www.virginiamedicaid.dmas.virginia.gov