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1 Department of Medical Assistance Services 1 Department of Medical Assistance Services.

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

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

3 3 Department of Medical Assistance Services 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 4 Department of Medical Assistance Services Table of Contents Waiver Screenings Slides 9-10 Waiver Enrollment Slides Screening Process Slides Tech Waiver EligibilitySlide 15 –Eligibility for ChildrenSlides –Eligibility for AdultsSlides 18-22

5 5 Department of Medical Assistance Services Table of Contents - continued Tech Waiver Referrals- Documentation RequirementsSlide 23 Waiver EnrollmentSlide 24 Respite EnrollmentSlide 25 Enrollment and ReimbursementSlide 26 Documentation Requirements Home Health Certification & Plan of Care (CMS- 485) Slides 27-33

6 6 Department of Medical Assistance Services Table of Contents - continued Orders for Skilled Nursing Care (CMS-485) Block 21 Slides RN Supervisory Responsibilities Slides RN Supervisor – Agency Transfers Slides Skilled Private Duty Nursing Slides Use of Two Nursing Providers Slides 52-54

7 7 Department of Medical Assistance Services Table of Contents - continued Supervisory Monthly Summary (DMAS 103)Slides Termination of ServicesSlides Interruption of ServicesSlide 65 Cessation of Technology Slide 66 Provider Discharge Responsibilities Slides 67-68

8 8 Department of Medical Assistance Services Table of Contents - continued Provider Discharge vs. Waiver TerminationSlides Tech Waiver Re-EnrollmentSlides –DMAS Responsibilities –Provider Responsibilities –DMAS Reimbursement Contacts: DMAS Health Care Coordinators and the Long Term Care Division Slide 80

9 9 Department of Medical Assistance Services Waiver Screenings

10 10 Department of Medical Assistance Services 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 11 Department of Medical Assistance Services 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 12 Department of Medical Assistance Services Waiver Enrollment (c ont. ) 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 13 Department of Medical Assistance Services Technology Assisted Waiver Screening Process

14 14 Department of Medical Assistance Services Technology Assisted Waiver Screening Process Further screening information may be found in the Pre-Admission Screening manual on the Virginia Medicaid Web Portal

15 15 Department of Medical Assistance Services WAIVER ELIGIBILITY

16 16 Department of Medical Assistance Services 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 17 Department of Medical Assistance Services 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 18 Department of Medical Assistance Services 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 19 Department of Medical Assistance Services 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 20 Department of Medical Assistance Services 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 21 Department of Medical Assistance Services 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 22 Department of Medical Assistance Services Waiver Eligibility for Adults Tech Waiver children reaching age 21 must meet adult medical needs and cost effectiveness standards for adults

23 23 Department of Medical Assistance Services 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 24 Department of Medical Assistance Services 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 25 Department of Medical Assistance Services 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 26 Department of Medical Assistance Services 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 27 Department of Medical Assistance Services Required Documentation Home Health Certification and Plan of Care CMS - 485

28 28 Department of Medical Assistance Services 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 29 Department of Medical Assistance Services 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 30 Department of Medical Assistance Services 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 31 Department of Medical Assistance Services 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 32 Department of Medical Assistance Services 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 33 Department of Medical Assistance Services 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 34 Department of Medical Assistance Services 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 35 Department of Medical Assistance Services 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 36 Department of Medical Assistance Services CMS 485, Block 21 (cont.) Tracheostomy – cont. 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 37 Department of Medical Assistance Services 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 38 Department of Medical Assistance Services 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 39 Department of Medical Assistance Services 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 40 Department of Medical Assistance Services 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 41 Department of Medical Assistance Services 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 42 Department of Medical Assistance Services 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 43 Department of Medical Assistance Services 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 44 Department of Medical Assistance Services 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 45 Department of Medical Assistance Services 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 46 Department of Medical Assistance Services 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 47 Department of Medical Assistance Services 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 48 Department of Medical Assistance Services 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 49 Department of Medical Assistance Services 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 50 Department of Medical Assistance Services 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 51 Department of Medical Assistance Services 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 52 Department of Medical Assistance Services USE OF TWO PDN PROVIDERS

53 53 Department of Medical Assistance Services 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 54 Department of Medical Assistance Services 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 55 Department of Medical Assistance Services Supervisor Monthly Summary (DMAS 103)

56 56 Department of Medical Assistance Services 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 57 Department of Medical Assistance Services 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 58 Department of Medical Assistance Services 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 59 Department of Medical Assistance Services 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 60 Department of Medical Assistance Services 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 61 Department of Medical Assistance Services 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 62 Department of Medical Assistance Services 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 63 Department of Medical Assistance Services Tech Waiver Termination of Services

64 64 Department of Medical Assistance Services 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 65 Department of Medical Assistance Services 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 66 Department of Medical Assistance Services 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 67 Department of Medical Assistance Services 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 68 Department of Medical Assistance Services 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 69 Department of Medical Assistance Services 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 70 Department of Medical Assistance Services 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 71 Department of Medical Assistance Services 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 72 Department of Medical Assistance Services 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 73 Department of Medical Assistance Services 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 74 Department of Medical Assistance Services 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 75 Department of Medical Assistance Services 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 76 Department of Medical Assistance Services 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 77 Department of Medical Assistance Services 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 78 Department of Medical Assistance Services Re-enrollment Provider Responsibilities F ollowing 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 79 Department of Medical Assistance Services 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 80 Department of Medical Assistance Services 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 81 Department of Medical Assistance Services


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