12 Va. Admin. Code § 30-122-100 - Modifications to or termination of services
A. DMAS or its designee shall have the
authority to approve modifications to an individual's ISP, based on the
recommendations of the support coordinator.
B. The provider shall be responsible for
modifying an individual's plan for supports, with the involvement of the
individual enrolled in the waiver and the individual's family/caregiver, as
appropriate, and submitting such revised plan for supports to the support
coordinator any time there is a modification in the individual's condition or
circumstances that may warrant a change in the amount or type of service
rendered by the provider.
1. The support
coordinator shall review the need for a modification and may recommend a
modification to the plan for supports to DBHDS. If the support coordinator does
not recommend a modification to the plan for supports and that results in the
denial of the requested service, the support coordinator shall inform the
individual of his right to appeal.
2. DBHDS shall approve, deny, or pend for
additional information the provider's requested modification to the
individual's plan for supports as recommended by the support coordinator. DBHDS
shall communicate its determination to the support coordinator within 10
business days of receiving all supporting documentation regarding the request
for modification or in the case of an emergency, within three business days of
receipt of the request for modification.
3. The individual enrolled in the waiver and
the individual's family/caregiver, as appropriate, shall be notified in writing
by the support coordinator of his right to appeal, pursuant to DMAS client
appeals regulations (12VAC30-110), all decisions to reduce, deny, or terminate
services. The support coordinator shall submit this written notification to the
individual enrolled in the waiver or the family/caregiver, as appropriate,
within 10 business days of the decision. Once the individual or
family/caregiver receives the written notification, the clock for filing an
appeal, as set forth in the DMAS client appeals regulations, shall begin to
run.
C. In an emergency
situation when the health, safety, or welfare of the individual enrolled in the
waiver, other individuals in that setting, or provider personnel are
endangered, the support coordinator and DBHDS shall be notified by the provider
prior to discontinuing services. The 10-business-day prior written notification
period shall not be required. The local department of social services adult
protective services unit or child protective services unit, as appropriate, and
the DBHDS Offices of Licensing and Human Rights and DMAS shall be notified
immediately of the emergency discontinuation of services by the support
coordinator and the provider when the individual's health, safety, or welfare
may be in danger.
D. In a
nonemergency situation, when a provider determines that his provision of
supports to an individual enrolled in the waiver will be discontinued, the
provider shall give the individual and the individual's family/caregiver, as
appropriate, and support coordinator written notification of the provider's
intent to discontinue services. The notification letter shall provide the
reasons for the planned discontinuation and the effective date the provider
will be discontinuing services. The effective date of the service
discontinuation shall be at least 10 business days after the date of the
notification letter. The individual enrolled in the waiver may seek services
from another enrolled provider. When an individual is transitioning to a
different provider, the former provider that served the individual shall, at
the request of the new provider, provide all medical records and documentation
of services to the new provider (consistent with confidentiality requirements,
including the Health Insurance Portability and Accountability Act and
12VAC35-115, Regulations to Assure the Rights of Individuals Receiving Services
from Providers Licensed, Funded, or Operated by the Department of Behavioral
Health and Developmental Services) to ensure high quality continuity of care
and service provision.
E. To
discontinue services in both emergency and nonemergency situations, providers
of group home residential services, supported living residential services, and
sponsored residential services shall comply with the terms set forth in an
individual's home and community-based settings residency or lease agreement as
described in 42 CFR 441.301.
F.
Support coordinators must inform DBHDS when an individual transitions from one
of the DD Waivers to the Medicaid Works program. Such individuals may retain
their DD Waiver slot for 180 days after the date of transition, although DD
Waiver services must be closed. After the 150-day period, DBHDS will notify the
support coordinator of the need to take action to terminate the slot. The
support coordinator will notify the individual and family/caregiver, as
appropriate, of this determination and the right to appeal, pursuant to
12VAC30-110, such termination in advance of the action.
G. The support coordinator shall have the
responsibility to identify those individuals who no longer meet the level of
functioning criteria (VIDES) or for whom home and community-based waiver
services are no longer an appropriate alternative. In such situations, DMAS or
its designee shall terminate such individuals from the waiver.
1. The support coordinator shall notify the
individual and family/caregiver, as appropriate, of this determination and the
right to appeal, pursuant to 12VAC30-110, such termination.
2. The individual shall be given the option
to continue his waiver services pending the final outcome of his appeal. Should
the outcome of the appeal confirm the determination by DMAS or its designee
that the individual should be terminated from the waiver, the individual may be
responsible for the costs of his waiver services incurred by DMAS during his
appeal as required by 12VAC 30-110-100.
Notes
Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
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