1. Technology Assisted (Tech) Waiver Highlights 2013
Department of Medical Assistance Services
Technology Assisted (Tech) Waiver Highlights 2013 1

2. Tech Waiver Highlights
The purpose of this training is to review key Technology Assisted Waiver policies and required documentation.

3. Tech Waiver Highlights
*This training is not all inclusive of Tech Waiver policy, procedures, and requirements *A complete Tech Waiver training may be found on the DMAS Website under Learning Network / Long Term Care

4. Table of Contents Waiver Screenings Slides 9-10
Waiver Enrollment Slides 11-12
Screening Process Slides 13-14
Tech Waiver Eligibility Slide 15
Eligibility for Children Slides 16-17
Eligibility for Adults Slides 18-22

5. Table of Contents - continued
Tech Waiver Referrals-
Documentation Requirements Slide 23
Waiver Enrollment Slide 24
Respite Enrollment Slide 25
Enrollment and Reimbursement Slide 26
Documentation Requirements
Home Health Certification & Plan of Care
(CMS- 485) Slides 27-33

6. Table of Contents - continued
Orders for Skilled Nursing Care
(CMS-485) Block Slides 34-39
RN Supervisory Responsibilities Slides 40-45
RN Supervisor – Agency Transfers Slides 46-48
Skilled Private Duty Nursing Slides 49-51
Use of Two Nursing Providers Slides 52-54

7. Table of Contents - continued
Supervisory Monthly Summary
(DMAS 103) Slides 55-62
Termination of Services Slides 63-64
Interruption of Services Slide 65
Cessation of Technology Slide 66
Provider Discharge Responsibilities Slides 67-68

8. Table of Contents - continued
Provider Discharge vs.
Waiver Termination Slides 69-71
Tech Waiver Re-Enrollment Slides 72-79
DMAS Responsibilities
Provider Responsibilities
DMAS Reimbursement
Contacts:
DMAS Health Care Coordinators and
the Long Term Care Division Slide 80

9. Tech Waiver Highlights
Waiver Screenings

10. Waiver Screenings
DMAS receives preadmission screenings for TW enrollment from Pre-Admission Screening (PAS) teams at the local Departments of Health and Social Services when the individual resides in the community
DMAS receives screenings for Tech Waiver enrollment from the discharge planner when the individual is in an acute care center
Pre- Admission Screenings are the same for both waiver populations ( children and adults) except for age appropriate assessments

11. Waiver Enrollment Waiver enrollment is dependent on:
Medicaid eligibility
A complete screening packet to include:
UAI, DMAS 96 & DMAS 97
Completion of age appropriate referral forms:
DMAS 108 (Adult Referral form) or
DMAS 109 (Pediatric Referral form)

12. Waiver Enrollment (cont.)
Is dependent on:
The individual is at risk for hospitalization
A safe and effective Plan of Care that meets the needs of the individual in a community setting
Assurance that Medicaid is the payer of last resort
DMAS approval of PDN services
Provider’s start of care

13. Technology Assisted Waiver Screening Process
Tech Waiver Highlights
Technology Assisted Waiver Screening Process

14. Technology Assisted Waiver Screening Process
Further screening information may be found in the Pre-Admission Screening manual on the Virginia Medicaid Web Portal

15. WAIVER ELIGIBILITY

16. Waiver Eligibility for Children
Children are individuals who are under age 21 years and
need a medical device and substantial and ongoing skilled nursing care when the individual meets one or more of the following requirements:
Dependent at least part of each day on a mechanical ventilator or
Requires prolonged intravenous administration of nutritional substances or drugs or ongoing peritoneal dialysis or

17. Waiver Eligibility for Children (cont.)
Has daily dependence on other device-based respiratory or nutritional support, including tracheostomy tube care, oxygen support, or tube feeding and
Has 50 points or more on the Pediatric Referral form,
(DMAS 109)

18. Waiver Eligibility for Adults
Adults are individuals who are age 21 years or older and
meet Medicaid specialized care criteria and need a medical device when A or B of the following
categories are met:
A- Individuals depending at least part of each day on a mechanical ventilator OR
B- Individuals who meet all eight of the Complex Tracheostomy criteria below:

19. Waiver Eligibility for Adults
(Complex Tracheostomy Criteria)
1. Tracheostomy with the inability to wean
2. Nebulizer treatments or nebulizer treatments followed by chest PT at least four times a day provided by a nurse and or respiratory therapist

20. Complex Tracheostomy Criteria (Cont.)
3. Requires pulse oximetry at least every 8 hours due to unstable oxygen saturation levels
4. Requires respiratory assessment by a respiratory therapist or a nurse
5. MD order for oxygen therapy with documented usage

21. Complex Tracheostomy Criteria (cont.)
6. Tracheostomy care at least daily
7. Tracheostomy suctioning PRN and as ordered by a MD and
8. Deemed at risk of requiring subsequent mechanical ventilation

22. Waiver Eligibility for Adults
Tech Waiver children reaching age 21 must meet adult medical needs and cost effectiveness standards for adults

23. Tech Waiver Referral Documentation
UAI Screening
DMAS 96 – Medicaid Long Term Care Authorization
DMAS 97- Recipient Choice-Institutional Care or Waiver Services
Age appropriate TW referral form:
DMAS 108-TW Adult Referral
DMAS 109-TW Pediatric Referral
All supporting medical documentation

24. Waiver Enrollment
DMAS will perform the following after enrollment is approved:
Review the provider RN Home Admission Assessment
(DMAS 116) and 485 (Plan of Care) as the final determination
for authorization of PDN
Confirm the start of care date for PDN
Enroll and create a Service Authorization in the DMAS (MMIS) system to allow for provider reimbursement and
Notify the provider and waiver individual of PDN authorization.

25. Waiver Enrollment Respite
Effective the provider must request Skilled Respite authorization from the DMAS contractor (KePRO)
Respite hours are used when the individual requests nursing hours in addition to the standard hours authorized by the DMAS Health Care Coordinator

26. Enrollment & Reimbursement
Medicaid shall not reimburse for any PDN hours provided prior to the DMAS authorization on the Technology Assisted Waiver Skilled Private Duty Nursing Authorization Form (DMAS 102)
Medicaid shall not reimburse for any home and community based care services delivered prior to:
The individual’s establishment of Medicaid eligibility
The date of the preadmission screening or
The physician’s signature on the DMAS 96- Medicaid Funded Long Term Care Services Authorization form

27. Required Documentation
Home Health Certification and Plan of Care CMS - 485

28. Plan of Care – CMS 485 Requirements
A complete initial Home Health Certification and Plan of Care (CMS-485) shall include all required documentation and must be signed and dated by an attending COMMUNITY physician

29. Plan of Care – CMS 485 Requirements
The certification/ recertification service plan must include:
All MD orders for SKILLED nursing care
Orders obtained as a result of modifications to the previous service plan, and existing orders that remain in effect

30. Plan of Care – CMS 485 Requirements
Providers choosing to use a form other than the Home Health Certification and Plan of Care (CMS 485), MUST include all components of the 485 and must include the statement of physician certification with a signature and date and must be approved by DMAS
Shall be kept in the individual’s medical record in the provider’s office

31. Plan of Care – CMS 485 Requirements
To assure that all of the care needs for the Tech Waiver individual are met, the most recent 485 or DMAS-designated service plan shall be kept in the individual’s home at all times
Modifications to the plan of care may occur in the form of a verbal order, they must be received signed and dated by the RN and MD, and must be included on the next 60 day re-certification 485

32. Plan of Care – CMS 485 Requirements
The Plan of Care shall include:
Identification of the primary care physician in the community who has agreed to manage the medical care of the individual in the community
The name and current address of the individual
The individual’s date of birth, Medicaid ID number, and Tech Waiver SOC date as well as the sixty day certification period

33. Plan of Care – CMS 485 Requirements
Diagnosis to support waiver services and corresponding ICD-9 Codes
All current medications and allergies
A list of all DME equipment
Goals for care and services and
The dated MD and RN signatures completing the form

34. Orders for Skilled Care (CMS 485, Block 21)
Orders for Discipline and Treatments must
include the following information for these
specific technologies:
BIPAP/ CPAP/ VENTILATORS
Machine or Vent model
Current MD ordered Vent settings
Orders for Vent use, ie.- time to be used, weaning schedule (if ordered)

35. CMS – 485, Block 21 (cont.) TRACHEOSTOMY
Trach manufacturer, size, and back up trach size
With cuff use - Please specify when cuff is to be inflated (with vent use, with sleep only, while eating, etc.) Inflate with air or water and amount
Trach Care to include:
Frequency of change and LOCATION if not done at home
Specific ostomy site care and frequency per day
Inner cannula care or change if applicable

36. CMS 485, Block 21 (cont.) Tracheostomy – cont. Oxygen Pulse Oximeter
Trach suction catheter size and frequency
Oxygen
Should be ordered as a medication to include dose/amount, time to be used (PRN /with sleep/ continuous), route
Pulse Oximeter
Include high/low limits and orders in response to exceeding those limits

37. CMS 485, Block 21 (cont.) Nutrition Specify PO, enteral feeding or TPN
Include specific PO diet, ie. consistency and indicate if thickener is required for liquids
Enteral feeding should specify formula name,
amount , frequency and delivery method
Gastrostomy site care, frequency of care, tube size, and changing schedule must be ordered

38. CMS 485, Block 21 (cont.) Catheter Care
Foley , size, change frequency, irrigation if ordered
Straight catheter, size, scheduled or PRN, irrigation if ordered
Wound Care
Site, type, specific treatment orders, measurements of wound if applicable
Include name and phone # of any agency that provides RN skilled wound care visits

39. CMS 485, BLOCK 21 (cont.) Infusion Therapy Type of infusion fluids
IV site, care orders
Dosage and daily time schedule for giving the infusion

40. RN SUPERVISOR RESPONSIBILITIES
The RN Supervisor is responsible for ensuring Technology Waiver nurses meet requirements set forth by DMAS. These requirements include but are not limited to:
Registered Nurses must be licensed to practice nursing in the Commonwealth of Virginia
Licensed Practical Nurses must be licensed to practice nursing in the Commonwealth of Virginia and must practice under the direct supervision of the agency RN supervisor

41. RN SUPERVISOR RESPONSIBILITIES
All nurses must have at least 6 months experience in the needs and care of the TW individual to include the care needs of children when the waiver individual is a child
All nurses must be deemed competent and trained to care for TW individuals with complex skilled needs such as tracheostomy and ventilator dependency
All nurses must have a DMAS 259 form completed by the RN supervisor prior to assignment to a Technology Waiver individual

42. RN SUPERVISOR RESPONSIBILITIES
RN supervisors shall review with each nurse all skills listed on the DMAS 259 form and have the nurse demonstrate or explain in detail how they would perform each task
Nurses may not complete the DMAS 259 form on themselves
PDN staff may not complete this form on their nursing peers
The completed DMAS 259 form should accurately represent the nurse’s competence, education, training and experience

43. RN SUPERVISOR RESPONSIBILITIES
RN supervisors must perform a face to face visit with each Tech Waiver individual monthly. Every other month, the visit must be made in the individual’s home
RN supervisors may not work as a private duty nurse on cases they supervise
RN supervisors must complete in its entirety, the Monthly Supervisory Assessment (DMAS 103) form and send to DMAS within 5 days of the end of the month reported
RN supervisors should ensure that required documentation is in the individual’s agency record (screening, PDN auth, admit letter)

44. RN SUPERVISOR RESPONSIBILITIES
RN supervisors shall ensure that all employees are aware of the requirements to report suspected abuse, neglect, or exploitation immediately to APS or CPS, as appropriate
* A civil penalty may be imposed on mandated reporters who do not report suspected abuse, neglect, or exploitation to VDSS as required
RN supervisors shall ensure services are provided in a manner that is in the best interest of the individual and does not endanger the individual’s health, safety, or welfare

45. RN SUPERVISOR RESPONSIBILITIES
RN supervisors must report to DMAS any unethical or incompetent practices that jeopardize public safety or cause a risk of harm to TW individuals
RN Supervisors shall ensure that all nurses and caregivers are aware that timesheets must be accurate with arrival and departure time of the nurse and that falsifying timesheets is Medicaid fraud
RN supervisors should ensure that respite documentation is kept separate from regular nursing documentation and labeled as respite

46. RN SUPERVISOR RESPONSIBILITIES Agency Transfers
RN Supervisors should coordinate transfer of an individual’s care to another private duty nursing provider whenever their agency is no longer able to sufficiently staff the individual’s care or the individual requests a transfer to another provider
RN Supervisors must contact DMAS staff to inform them of the need to transfer a TW individual, the provider chosen to accept the TW individual, and the effective date of the transfer

47. RN SUPERVISOR RESPONSIBILITIES
RN Supervisors should instruct caregivers to contact DMAS staff to inform them of their decision to transfer providers
The transferring provider must send to the accepting private duty nursing provider the following information:
A letter stating the last date of service to be rendered by the transferring agency and the reason for the transfer (agency initiated transfers)
A copy of the current plan of care (CMS 485) and any additional physician orders received during the current certification period

48. RN SUPERVISOR RESPONSIBILITIES
Transferring Provider Continued:
A copy of the individual's waiver screening (UAI, DMAS-96, DMAS-97, DMAS-108 or DMAS-109 as appropriate)
A copy of the most recent monthly nursing assessment (DMAS 103)
The number of respite hours used within the current year

49. SKILLED PRIVATE DUTY NURSING
PDN must be performed in the primary residence of the waiver individual with some community integration. The provider is responsible for notifying DMAS when a change in primary residence occurs
Nurses may not drive individuals in a vehicle, however they may accompany the individual in a vehicle when necessary (i.e. medical appointments, school, etc.)
When PDN hours are provided at school, the nurse must be able to observe and assess the individual at all times

50. SKILLED PRIVATE DUTY NURSING
Skilled PDN Nursing documentation must be completed each day and kept in the individual’s home
When necessary to remove nursing documentation from the home, nurses must ensure HIPAA guidelines are followed to protect patient health information
A binder should be kept in the home that contains a copy of the current 485, physician orders written during the certification period, medication administration records, treatment records, nursing assessments and documentation, etc. These binders should be organized and old information should be removed routinely

51. SKILLED PRIVATE DUTY NURSING
Nurses shall keep medical documentation in a designated place in the home and assure confidentiality is maintained in accordance with all HIPAA guidelines. Caregivers should know the location of the nursing binder in the home

52. USE OF TWO PDN PROVIDERS

53. USE OF TWO PDN PROVIDERS
The following applies when two private duty nursing agencies provide services to the same Tech Waiver individual:
Coordination of services must be assured
Both providers shall maintain a medical record for the individual with all required documentation
Both providers must have a coordinated CMS 485, medication record and nurses notes

54. Two Providers for the Same Individual (CONT.)
Both providers must track the annual respite hours used and not exceed their authorized number of respite hours
Each provider may only provide nursing hours authorized for their agency
Any change in hours for either agency must be preapproved by DMAS Health Care Coordinator

55. Supervisor Monthly Summary (DMAS 103)

56. Supervisor Monthly Summary - (DMAS 103)
A RN Monthly Summary (DMAS 103) must be completed by the RN Supervisor each month for Technology Assisted Waiver individuals and sent to DMAS
Monthly reports are essential to DMAS for ongoing monitoring of the Tech Waiver individual’s condition, services received and social situation
The RN Monthly Supervisory Report (DMAS 103) must be submitted to DMAS within 5 days following the end of the month in which the visit is done

57. Supervisor Monthly Summary - (DMAS 103)
Completing the DMAS Definitions
“Primary Caregiver” is the TW individual’s primary caregiver not the nurse
“Tech Waiver Participant” means the name of the TW individual (this is not a yes/no question)

58. Supervisor Monthly Summary - (DMAS 103)
“Health, safety and welfare needs met?”- if answering no, as a mandated reporter you must contact CPS or APS and notify the individual’s Health Care Coordinator
Respite hours provided - document the number of respite hours provided that month
Total respite hours used to date - document the total number of respite hours used for the current calendar year

59. Supervisor Monthly Summary - (DMAS 103)
Clinical status this month-please do not document “no changes”
Document findings of RN assessment performed at monthly visit, MD appointments and changes in orders, procedures, etc.

60. Supervisor Monthly Summary - (DMAS 103)
Notify the Health Care Coordinator by phone rather than simply documenting on the monthly report for changes or discontinuation in technology (NGT to GT, removal of trach, weaning from ventilator, etc.) These changes may affect an individual’s eligibility for TW services or the number of nursing hours authorized
Technology/Nursing Needs-please circle each form of technology used and frequency if appropriate
Current MD plan of treatment in the home chart - home record should contain current 485 at all times

61. Supervisor Monthly Summary -(DMAS 103)
Copy sent to DMAS – a new CMS 485 should be sent to the DMAS Health Care Coordinator at the beginning of each new certification period
Date of contact with family/caregiver - RN supervisor should be in contact with primary caregiver monthly in person at visit or by phone to assess service satisfaction
Nurses staffing case this month – notify the Health Care Coordinator for any lapse in nursing services, if the individual moves or has no nursing for 30 days and immediately if the individual dies

62. Supervisor Monthly Summary - (DMAS 103)
Problems identified - notify the DMAS Health Care Coordinator by phone of any major problem or change in family/social situation in addition to documenting on the RN Monthly report form

63. Termination of Services
Tech Waiver
Termination of Services

64. Waiver Termination is Performed by DMAS Only
Reasons for Waiver Termination:
Home care services are no longer the alternative to institutional placement
The individual is no longer Medicaid eligible
The individual’s environment does not provide for his/her health, safety and welfare

65. Termination Due to Interruption of Service Delivery
Waiver termination occurs when:
Skilled private duty nursing services are interrupted for greater than 30 days
The individual is admitted to a nursing facility, specialized care facility or inpatient rehab
The individual no longer meets Tech Waiver criteria
The individual is no longer a Virginia resident
Individuals admitted to a medical facility for less than 30 days are waiver eligible upon discharge if they continue to meet Tech Waiver criteria. The provider must contact DMAS prior to beginning nursing services at home

66. Termination due to Cessation of Technology
Children must meet criteria on the Pediatric Referral form
(DMAS 109) with a minimum of 50 points
Adults over age 21 must meet criteria in Group A or B on the Adult Referral form (DMAS 108)
A child or adult who no longer meets the qualifications of
12VAC C may be eligible for private duty nursing hours as previously approved, not to exceed two weeks from the date the physician certifies the cessation of technology assistance
When appropriate, the provider RN Supervisor should coordinate with DMAS for a decrease in hours during this period

67. Provider Discharge Responsibilities
The provider RN Supervisor must be aware of the pediatric and adult Tech Waiver criteria to ensure that individuals continue to qualify for the waiver
Supervisors should assess during monthly RN Supervisory visits if individuals continues to meet criteria. The DMAS Coordinator must be notified immediately if the Supervisor believes the individual does not meet waiver criteria

68. Provider Discharge Responsibilities
The RN Supervisor must contact the DMAS Coordinator immediately if technology (i.e. trach, vent, feeding tube) is discontinued for the waiver individual

69. Provider Discharge Versus Tech Waiver Termination
Waiver termination is completed by DMAS
Providers may discharge individuals from agency services
Providers must provide written notification of discharge to the waiver individual with 14 days notice (plus 3 days for mailing)
Notification must include the reason for discharge and the effective date

70. Provider Discharge (cont.)
A copy of the notification must be sent to the DMAS Care Coordinator immediately
The Supervisor must complete the DMAS- 225 form and send it to the local DSS office and the DMAS Coordinator
The provider must notify the DMAS Coordinator immediately if an individual dies
A provider may discharge an individual in an emergency without written notice when the health and safety of the individual or agency personnel are endangered

71. Provider Discharge (cont.)
The RN Supervisor must call a DMAS Coordinator immediately if individual or personnel safety is endangered
The provider must contact Adult or Child Protective Services immediately when appropriate

72. Tech Waiver Re-enrollment
Previous Tech Waiver enrollees may be re-enrolled in the waiver by contacting a DMAS Coordinator prior to the start of nursing care The RN Supervisor must contact DMAS to assure that DMAS has received required documents for re-enrollment Prior to the start of care DMAS will review the skilled needs, Medicaid eligibility and private third party insurance if available

73. Tech Waiver Re-enrollment DMAS Responsibilities
The DMAS Coordinator’s assessment for waiver enrollment includes all screening documents and supporting information to assure:
DMAS is the payer of last resort
There is no duplication of service
Tech Waiver criteria are met
Physician orders for services are received
There is a safe, effective plan of care

74. Re-enrollment Provider Responsibilities
Upon receiving approval for re-enrollment from the DMAS Coordinator the provider may begin nursing services
The provider must complete the RN Home Assessment using the (DMAS 116) form prior to starting nursing and notify the DMAS Coordinator when the first nursing shift is worked which is the start of care date

75. Re-enrollment Provider Responsibilities
The Supervisor must send the RN Home Assessment (DMAS 116) and a Home Health Certification and Plan of Care (CMS 485) to DMAS within 48 hours of the start of care
A service authorization number will not be provided prior to receiving this documentation

76. Re-enrollment Provider Responsibilities
The provider must place a copy of all physician orders in the individual’s home chart for private duty nursing staff on the first day of service. The CMS 485 should be completed within 48 hours
Nurses may not provide care without written orders available in the home

77. Re-enrollment Provider Responsibilities
Tech Waiver Highlights
Re-enrollment Provider Responsibilities
Specific physician orders for the individual’s skilled needs must be documented on the Plan of Care (CMS 485) to include but not limited to:
Specific trach care procedures
Ventilator settings
Gastrostomy tube care
Feeding orders

78. Re-enrollment Provider Responsibilities
Following re-enrollment and the start of care the provider must send a (DMAS 225) form to the local DSS office and DMAS
Providers are responsible for knowledge of any patient pay amount and collection of payment

79. Re-enrollment DMAS Reimbursement
Providers must call a DMAS Coordinator PRIOR to starting nursing services for service approval
Medicaid will not reimburse for private duty nursing hours provided prior to the DMAS authorization date on the Technology Assisted Waiver Skilled Private Duty Nursing Authorization form (DMAS 102)

80. DMAS Health Care Coordinators
Rebecca Stricklin, RN
Roberta Matthews, RN
Laura Epperly, RN
Susan Heller, RN
Diane Gilbert, RN
DMAS LONG TERM CARE TECH WAIVER–
FAX

81. Thank you for viewing The tech waiver highlights 2013!