Personal Care and Respite Training 2009

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2. 2 Personal Care and Respite What is a Medicaid Waiver? Waiver Eligibility Criteria Personal Care Services Respite Care Services Companion Care Services Staffing Requirements Documentation QMR

3. 3 What is a Waiver? A Waiver permits state Medicaid agencies, to waive certain requirements and develop services to meet special needs or target underserved areas Waivers have defined criteria and limits Waivers must be approved by Centers for Medicare and Medicaid (CMS)

4. 4 What is a Waiver?Common Waiver Elements They must be applied for Approved initially for 3 years, then in 5 year increments There must be an alternate institutional placement for which Medicaid pays

5. 5 The participant applying must meet the same criteria that is used for admission to the alternative institutional placement Choice of placement, providers and services must be provided and documented Cost effectiveness must be met Waiver funds cannot pay for room and board What is a Waiver?Common Waiver Elements, cont’d.

6. 6 What is a Waiver ? Alternate Institutional Placement The nursing facility is the alternate institutional placement for HIV/AIDS Waiver Elderly or Disabled with Consumer Direction (EDCD) Waiver The Long-Stay Hospital or Specialized Care Units in nursing facilities are the alternate institutional placement for Technology Assisted Waiver (Tech)

7. 7 What is a Waiver? Alternate Institutional Placement An Intermediate Care Facility for the Mentally Retarded (ICFMR) is the alternate institutional placement the Day Support (DS) Waiver Individual and Family Developmental Disabilities Support (IFDDS) Waiver Intellectual Disabilities/Mental Retardation (ID/MR) Waiver

8. 8 What is a Waiver? Waiver Enrollment Criteria Meet the following: General Medicaid Eligibility (financial) Functional needs (clinical) Medical nursing needs Functional Eligibility

9. 9 Recipient Choice The applicant must be offered the choice in all of the following: Waiver vs. Alternate Institutional Placement Providers Services

10. 10 What is a Waiver? Waivers are a partnership between the family support system and Medicaid providers to assist an individual living in the community who might otherwise reside in an institution Waivers do not provide 24 hours of care or equal services of the alternate institutional care Waivers offer services not available from regular Medicaid services (state plan or state plan options)

11. 11 Personal Care and Respite What is a Medicaid Waiver? Waiver Eligibility Criteria Personal Care Services Respite Care Services Companion Care Services Staffing Requirements Documentation QMR

12. 12 Medicaid Eligibility Who can be eligible? Any resident of the Commonwealth who meets the eligibility requirements Who determines eligibility? Local Department of Social Services conduct screening for eligibility (financial) Screenings include: Categorical Eligibility Financial Eligibility

13. 13 Medicaid Eligibility-Two Parts: Categorical Eligibility Aged, blind, and disabled Families with children Recipients of cash assistance Pregnant women and children Low income Medicare Beneficiaries

14. 14 Medicaid Eligibility-Two Parts: Financial Eligibility After meeting a category, the individual must meet income and asset guidelines, as well as non-financial criteria. Use the same form for children and adults Can make determination based only on applicant’s income if a child

15. 15 Waiver Eligibility Who determines waiver eligibility? HIV/AIDS Waiver Elderly or Disabled with Consumer Direction (EDCD) Waiver Technology Assisted Waiver (Tech) Local DSS and Health Department conducts screening Acute Care Hospital (only if being discharged from the hospital)

16. 16 Waiver Eligibility Who determines waiver eligibility? Day Support (DS) Waiver Intellectual Disabilities/Mental Retardation (ID/MR) Waiver Community Service Boards conduct Level of Functioning Survey (LOF) for this waiver. Local DSS determines financial eligibility for Medicaid.

17. 17 Waiver Eligibility Who determines waiver eligibility Individual and Family Developmental Disabilities Support (IFDDS) Waiver Child Development Centers conduct Level of Functioning (LOF) Survey for this waiver. Local DSS determines financial eligibility for Medicaid.

18. 18 Who is Eligible for Waivers? General facts Services may be furnished only to persons: Who are eligible for Medicaid Who meet the criteria as determined by the screening team; If the individual is already Medicaid eligible, he/she must still have Medicaid eligibility re-determined when applying for Waiver services

19. 19 Who is Eligible for Waiver? Individual Facts An appropriate cost-effective plan of care must be established; Must have a safe plan to live in community. Have a caregiver with backup system in place. Be willing to accept care in the community. Be residents of the Commonwealth of Virginia

20. 20 Personal Care and Respite What is a Medicaid Waiver? Waiver Eligibility Criteria Enrollment/Disenrollment Personal and Respite Care Services Companion Care Services Staffing Requirements Documentation QMR

21. 21 Enrollment Process Must begin services with in 30 days Agency provider must: Have RN develop plan of care Receive prior authorization for each service in plan of care Submit DMAS 98 to KePRO along with required documentation. The case manager submits the DMAS 98 for DD Waiver. ISAR to Case Manager who submits to DBHDS

22. 22 Waiver Disenrollment Reasons Transfer to another waiver Admission to Nursing facility, Rehab, ICF/MR Services no longer meet services needs No longer meets Medicaid eligibility No longer meets waiver criteria No longer resides in Virginia No longer has a safe plan of care or back up

23. 23 Disenrollment Provider Actions When: Services not needed or becomes ineligible Ensure Prior Authorization agency receives end date for PA’s Providers will still need to complete the DMAS-225 anytime a person is admitted, re-admitted or discharged from care and will need to send a DMAS-225 when there is a change that could impact how the DSS worker evaluates eligibility.

24. 24 EDCD and AIDS Waiver Provider Actions when: Admission to a Nursing Facility (NF) or Inpatient Rehabilitation, the Waiver enrollment is automatically terminated. (DMAS 225 must still be completed) Upon discharge, the Waiver provider must perform a new assessment, plan of care, etc. and request pre-authorization for enrollment and services as for a new enrollment (re-admission).

25. 25 EDCD and Aids Waiver A new screening is not needed unless more than 180 days have passed since the recipient received NF or Waiver services, at which time an update to the screening is needed. If more than 365 days have passed, a new screening is required.

26. 26 Cannot be served in more than one waiver at a time (federal requirement). Can be on one waiver while on a waiting list for another waiver if meets the criteria for admission to both waivers.

27. 27 Personal Care and Respite What is a Medicaid Waiver? Waiver Eligibility Criteria Enrollment/Disenrollment Personal and Respite Care Services Companion Care Services Staffing Requirements Documentation QMR

28. 28 Personal and Respite Care Criteria 12VAC30-120-90. Covered services and provider requirements. 12VAC30-120-180. Agency-directed personal care services. (AIDS Waiver) 12VAC30-120-190. Agency-directed respite care services. (AIDS Waiver) 12VAC30-120-233. Personal assistance and respite services. (ID/MR Waiver)

29. 29 Personal and Respite Care Criteria 12VAC30-120-766. Personal care and respite care services. (DD Waiver) 12VAC30-120-950. Agency-directed personal care services. (EDCD Waiver) 12VAC30-120-960. Agency-directed respite care services. (EDCD Waiver) Must have emergency back-up plan or is not eligible for this service. (DD waiver) Backup support plan for the EDCD Waiver. A backup plan must be identified in the ISP for ID/MR Waiver. Individuals who do not have a back-up plan are not eligible for personal care services. There must be a viable back-up identified in the POC. If no backup plan then individual is not eligible for personal care services. Must have emergency back-up plan or is not eligible for this service. (DD waiver) Backup support plan for the EDCD Waiver. A backup plan must be identified in the ISP for ID/MR Waiver. Individuals who do not have a back-up plan are not eligible for personal care services. There must be a viable back-up identified in the POC. If no backup plan then individual is not eligible for personal care services.

30. 30 Personal and Respite Care Criteria DMAS-97A/B-completed prior to start of care Initial Visit by RN for agency-directed Level of care (LOC) is assigned based on composite ADL score- Level A, B, or C LOC determines maximum # of hrs/week that may be allocated to the POC Any hours beyond the maximum must be preauthorized by Prior Authorization Contractor - KePRO or DBHDS

31. 31 Personal and Respite Care Criteria Personal Care consists of: Agency or consumer-directed options ADL and IADL supports to persons depending on the plan of care developed by the provider agency after assessment of the individual and their needs. Special Maintenance and Supervision Supervisory visits depending on individuals needs. Every 30-90 days.

32. 32 Personal and Respite Care Criteria Personal Care consists of: Provider agency will obtain prior authorization Via PA contractor (KePRO) before beginning services. (10 day retro period) for AIDS, EDCD, DD and Tech Waivers Via DBHDS for the ID/MR waiver

33. 33 Personal and Respite Care Criteria Respite Care (agency or consumer-directed options) Respite is relief for the unpaid primary caregiver who is providing the care the portion of the day not covered by a waiver provider Cannot be respite for paid caregiver Is offered to individuals in their home or place of residence

34. 34 Personal and Respite Care Criteria LIMITS Only allowed 720 hour a calendar year of respite in total Used for shopping, outings with friends/family, to have time to oneself, get healthcare, etc (for caregiver) Cannot be considered a routine service to extend care hours

35. 35 Personal and Respite Care Criteria Skilled Respite – the person has a routine skilled care that must be delivered by a licensed personnel. Individual is on a ventilator Individuals requiring nasogastric or gastrostomy feeding No one else in the person’s support system is available to perform service.

36. 36 Personal and Respite Care Criteria When respite care services are received on a routine basis, the minimum acceptable frequency of these supervisory visits shall occur every 30 to 90 days dependent on the cognitive status of the individual. If an individual is also receiving personal care services, the respite care RN supervisory visit may coincide with the personal care RN supervisory visits.

37. 37 Personal and Respite Care Criteria When respite care services are not received on a routine basis, but are episodic in nature, a registered nurse supervisor or residential supervisor shall not be required to conduct a supervisory visit every 30 to 90 days.

38. 38 Personal and Respite Care Criteria Instead, a registered nurse supervisor shall conduct the initial home assessment visit with the aide/LPN on or before the start of care and make a second home visit during the second respite care visit. If an individual is also receiving personal care services, the respite care RN supervisory visit may coincide with the personal care RN supervisory visit.

39. 39 COMPANION CARE DEFINITION Purpose is to supervise or monitor consumers who require physical presence of aide to ensure safety when no other caregiver is available Available in ID/MR and DD Waivers ID/MR takes place in the home or various location in the community.ID/MR takes place in the home or various location in the community.

40. 40 Companion Care, cont’d. Non-medical care and supervision provided to functionally impaired adult No hands-on nursing care Not sole service in Waiver to divert individual from institutionalization Must be clear and present danger to individual if left unsupervised

41. 41 Companion Care Criteria Included in Plan of Care only when individual can never be left alone due to mental or severe physical incapacitation. Includes individuals who cannot use phone to call for help For individuals whom a Personal Emergency Response System is not appropriate ID/MR light housekeeping, community access medication, self administration or support to ensure safety. Companion shall not be Adult Foster Care (AFC) provider or any other paid caregivers living in the home. ID/MR light housekeeping, community access medication, self administration or support to ensure safety. Companion shall not be Adult Foster Care (AFC) provider or any other paid caregivers living in the home.

42. 42 Companion Care Service Units and Limitations Billed hourly and must be prior authorized by KePRO (DD) or DBHDS (ID/MR) May not exceed 8 hours a day, and must be well documented. Not for individuals on ventilators, continuous tube feeds, or those requiring suctioning Documented on 97 and 457 for DD waiver. Documented on a ISP Refer audience to ID/MR manual or the DD Waiver manual for specific criteria for documentationDocumented on 97 and 457 for DD waiver. Documented on a ISP Refer audience to ID/MR manual or the DD Waiver manual for specific criteria for documentation

43. 43 Personal Care and Respite What is a Medicaid Waiver Waiver Eligibility Criteria Enrollment/Disenrollment Personal and Respite Care Services Companion Care Services Staffing Requirements Documentation QMR

44. 44 Staffing Requirements All Staff Two (2) satisfactory reference checks from prior job experience, including no evidence of abuse, neglect, or exploitation of incapacitated or older adults and children, recorded in the personnel file. Must comply with § 32.1-162.9:1 of the Code of Virginia regarding criminal record checks.

45. 45 Staffing Requirements Registered Nurse (RN) The provider must employ (or subcontract) and directly supervise a registered nurse (RN) who will provide ongoing supervision of all personal care aides.

46. 46 Staffing Requirements The RN must be licensed to practice in the Commonwealth of Virginia and have at least two (2) years of related clinical experience as a RN or a licensed practical nurse (LPN). Clinical experience may include work in an acute care hospital, public health clinic, home health agency, rehabilitation hospital, or nursing facility.

47. 47 Staffing Requirements Licensed Practical Nurse (LPN) Through the respite care program, the provider may be reimbursed for the services of a LPN currently able to practice in the Commonwealth of Virginia as long as the service is ordered by a physician and the provider can document the individual’s skilled needs.

48. 48 Staffing Requirements DMAS will reimburse for LPN respite care for those recipients who require the skilled level of care and who meet the criteria below. The circumstances that warrant provision of respite care by a LPN are: The recipient receiving care has a need for routine skilled care that cannot be provided by unlicensed personnel (i.e., recipient on a ventilator, recipient requiring nasogastric or gastrostomy feedings, etc.);

49. 49 Staffing Requirements No other individual in the recipient’s support system is able to provide the skilled component of the individual’s care during the caregiver’s absence;

50. 50 Staffing Requirements Personal Care Aide Each personal care aide hired by the provider must be evaluated by the provider to ensure compliance with qualifications as required by DMAS. Basic qualifications for personal care aides include: Physical ability to do the work; 18 years or older; Ability to read and write in English to the degree necessary to perform the expected tasks and posses basic math skills;

51. 51 Staffing Requirements Item 306 SSS from the 2009 Appropriations Act: The Department of Medical Assistance Services shall provide information to personal care agency providers regarding the options available to meet staffing requirements for personal care aides including the completion of provider-offered training or DMAS Personal Care Aide Training Curriculum.

52. 52 Staffing Requirements Qualifications can be met in one of three ways: Registration as a Certified Nurses Aide Graduation from an Approved Educational Curriculum that the board of nursing have approved. Provider-Offered Training approved providers can be found on the DMAS website at www.dmas.virginia.gov

53. 53 Staffing Requirements The Personal Care Aide Training Curriculum is located at the DMAS website. www.dmas.virginia.gov

54. 54 The Personal Care Aide Training Curriculum is located at the DMAS website. www.dmas.virginia.gov

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57. 57 Personal Care and Respite What is a Medicaid Waiver Waiver Eligibility Criteria Enrollment/Disenrollment Personal and Respite Care Services Companion Care Services Staffing Requirements Documentation QMR

58. 58 Top Documentation Errors AIDE RECORDS Incomplete documentation Not showing what was done or time completed Having participants sign blank aide records No participants signature on aide record, or Weekly aide notes not in chart Signatures not on record

59. 59 Top Documentation Errors RESPITE Respite hours used without participants or family requesting/knowing Respite provided for paid caregivers Respite being provided when there is not a primary caregiver

60. 60 STAFF No criminal record checks No child protective services checks when applicable No training certificates Not licensed appropriately Top Documentation Errors

61. 61 Top Documentation Errors DOCUMENTATION Family providing care and not being documented as to why they are providing the care Not documenting skilled need Supervisory visits are often exactly the same month to month, not occurring or are late

62. 62 POC Not being updated Missing from chart Not developing or knowing how to develop or update POC Top Documentation Errors

63. 63 Top Documentation Errors TRAINING 40 hrs. personal care aide training not documented RN did not do the training Certificate not in record Certificate not valid RN or LPN does not have license

64. 64 Personal Care and Respite What is a Medicaid Waiver Waiver Eligibility Criteria Enrollment/Disenrollment Personal and Respite Care Services Staffing Requirements Documentation QMR

65. 65 QMR Today Provides a full compliment of review activities On Site and desk Focus on health and safety More reviews than in years past Incorporates CMS 18 assurances and performance measures Technical Assistance provided Corrective action plans

66. 66 Quality Management Cycle

67. 67 Design

68. 68 Design Virginia Medicaid agency collects, aggregates and analyzes quantitative/qualitative data from: record reviews participant feedback surveys focus groups participant/provider interviews incident management database complaint database analysis paid claims other sources

69. 69 Design Evidence is analyzed and information is used to remediate and improve services and supports

70. 70 Discovery

71. 71 Discovery QMR Process Provider reviews DSS data bridge (Critical Incident Reports) Licensing Status Participant interviews Level of Care annual reviews (LOCERI) Provider participation agreement review Financial review

72. 72 Discovery - QMR Reviews Focusing on Health, Safety and Welfare 18 assurances and performance measures Participant not provider based DMAS is conducting more reviews

73. 73 Discovery - LOCERI Team This is an internal DMAS team that validates LOC annually This is a desk review Purpose: To insure all participants meet waiver criteria To insure plans of care meet participant needs Monitor providers meeting transfer of discharge of participants correctly

74. 74 Discovery - LOCERI cont’d. Actions May have to submit additional information. May have to withdraw person from waiver

75. 75 Discovery - Provider Review Provider Review This is the review on a routine basis of critical enrollment information. Examples: Licensing or certification Staff certification and/or training Organizational change Provider Policy & Procedures

76. 76 Discovery - Financial Financial Review This is the current review that occurs during the submission of monthly claims Edits in system validate claims

77. 77 Remediation

78. 78 Remediation - What Is It? A true Partnership that corrects issues to enhance individual services Providers conduct internal reviews/ self monitor It’s up to you DMAS conducts reviews and monitors corrective action

79. 79 Quality Improvement Team (QIT) monitors trends Trends are shared with providers for action Trainings Memo’s Manual updates Remediation - What Is It?

80. 80 Aggregated data from QMR reviews Items that will get Corrective Action Plans Patterns of lack of completed criminal record checks lack of providing choice documentation lack of completing annual LOC review / not meeting LOC lack of maintaining updated service plans lack of completing annual staff training any behavior that may be placing a participant at risk for health and safety Remediation- Some Waiver Triggers

81. 81 Improvement

82. 82 Improvement - Examples Providers will Take corrective action Develop internal controls DMAS will provide training: QMR process QMR expectations Targeted reviews New providers Termination of provider agreements

83. 83 Contact InformationLong-Term Care Division Division of Long-Term Care Telephone 804-225-4222 Fax 804-371-4986 www.dmas.virginia.gov

84. 84 Contact Information Prior Authorization KePRO Telephone 1-888-VAPAUTH (827-2884) or 804-622-8900 Fax1-877-OKBYFAX (652-9329) providerissues@kepro.org  or PAUR06@dmas.virginia.gov

85. 85 Contact Information Prior Authorization Department of Behavioral Health and Developmental Services ISAR submitted through Case Managers http://www.dbhds.virginia.gov Under Office of Developmental Services Click on MR Waiver and Day Support Waiver

86. 86 Contact InformationLong-Term Care Division Terry Smith, Division Director 804-371-8490 Program Managers: Steve Ankiel (804) 371-8894 Helen Leonard (804) 768-2149 William Butler (804) 371-8886

87. 87 Supervisors Yvonne Goodman- DD/Tech ( 804-786-0503) Tracy Harris, Lead Analyst for DD (804-225-4791) Deborah Pegram- PACE (804-371-2912) Melissa Fritzman- QMR (804-225-4206) Contact InformationLong-Term Care Division