Department of Medical Assistance Services Nursing Facility Services

1
Department of Medical Assistance Services
Nursing Facility Services
Melissa A. Fritzman Program Supervisor Division
of Long-Term Care Fall 2008
2
How Do I Know If I Meet Criteria?

• Nursing Facilitys Responsibility for Ensuring
  Residents Meet Criteria for Placement

3
Regulatory Support

• Section 12 VAC 30-60-300 of the Virginia
  Administrative Codes states the following
• Prior to an individual's admission, the nursing
  facility must review the completed pre-admission
  screening forms to ensure that appropriate
  nursing facility admission criteria have been
  documented.

4
Additionally

• The nursing facility is also responsible for
  documenting, upon admission and on an ongoing
  basis, that the individual meets nursing facility
  criteria and that the individual continues to
  meet nursing facility criteria based on the
  completion of the MDS.

5
Which Assessment Tool?

• For this purpose, the nursing facility will use
  the Minimum Data Set (MDS)

6
When Should the MDS be Completed?

• The post admission assessment must be conducted
• no later than 14 days after the date of admission
  and/or
• promptly after a significant change in the
  resident's physical or mental condition.

7
Use of MDS cont.

• If at any time during the course of the
  resident's stay, it is determined that the
  resident does not meet nursing facility criteria
  as defined in the State Plan for Medical
  Assistance, the nursing facility must initiate
  discharge of such resident.
• The facility must ensure the resident is
  discharged appropriately.

8
What is the Criteria for Continued Stay in a
Nursing Facility?

• Individuals may be considered appropriate for
  nursing facility care when one of the following
  describes their medical or nursing needs and
  functional capacities recorded on the Minimum
  Data set of the Resident Assessment Instrument.

9
What is the Criteria for Continued Stay in a
Nursing Facility? Cont.

• A. Functional Capacity
• 1. Rated dependent in two to four of the ADLs,
  and also rated semi-dependent or dependent in
  Behavior Pattern and Orientation, and
  semi-dependent in Joint Motion or dependent in
  Medication Administration. (12 VAC 30-60-303) or
  

10
What is the Criteria for Continued Stay in a
Nursing Facility? Cont.

• B. Medical or Nursing Needs
• 1. The individual has health needs that require
  medical or nursing supervision or care above the
  level, which could be provided through assistance
  with ADLs, medication administration, and general
  supervision and is not primarily for the care and
  treatment of mental diseases.

11
What is the Criteria for Continued Stay in a
Nursing Facility? Cont.

• A. Functional Capacity
• 2. Rated dependent in five to seven of the ADLs,
  and also rated dependent in Mobility or
• 3. Rated semi-dependent in two to seven of the
  ADLs, and also rated dependent in Mobility and
  Behavior Pattern and Orientation.

12
Definitions to be Applied When Completing MDS
ADLs

• Transfer Section G(1)(b)(A) In order to meet
  this ADL, the individual must score a 1, 2, 3, 4,
  or 8 as described below
• (0) Independent No help or oversight OR help or
  oversight provided only 1 or 2 times during last
  7 days.
• (1) Supervision Oversight, encouragement, or
  cuing provided 3 times during last 7 days OR
  supervision plus physical assistance provided 1
  or 2 times during last 7 days.

13
Definitions to be Applied When Completing MDS
ADLs

• Transfer Section G(1)(b)(A) In order to meet
  this ADL, the individual must score a 1, 2, 3, 4,
  or 8 as described below
• (2) Limited Assistance Resident highly involved
  in activity received physical help in guided
  maneuvering of limbs or other non-weight-bearing
  assistance 3 times OR more help provided only 1
  or 2 times during last 7 days.

14
Definitions to be Applied When Completing MDS
ADLs cont..

• (3) Extensive Assistance While resident
  performed part of activity over last 7-day
  period, help of following type or types was
  provided 3 or more times weight-bearing support
  or full staff performance during part (but not
  all) of last 7 days.

15
Definitions to be Applied When Completing MDS
ADLs cont..

• (4) Total Dependence Full staff performance of
  activity during entire 7 days.
• (8) Activity Did Not Occur During the Entire
  7-day Period Use of this code is limited to
  situations where the ADL activity was not
  performed and is primarily applicable to fully
  bed-bound residents, who neither transferred from
  bed nor moved between locations over the entire
  7-day period.

16
Definitions to be Applied When Completing MDS
ADLs cont..

• Dressing G(1)(g)(A) In order to meet this
  ADL, the individual must score a 1, 2, 3, 4, or 8
  (definitions are the same as described for
  Transferring)
• Eating G(1)(h)(A) In order to meet this ADL,
  the individual must score a 1, 2, 3, 4, or 8
  (definitions are the same as described for
  Transferring)
• Or Under Section G, one of the following is
  checked
• (1) K(5)(a) - Parenteral or intravenous.
• (2) K(5)(b) - Feeding tube.
• (3) K(5)(d) - Syringe (oral feeding).

17
Definitions to be Applied When Completing MDS
ADLs cont..

• Toilet Use G(1)(i)(A) In order to meet this
  ADL, the individual must score a 1, 2, 3, 4, or 8
  (definitions are the same as described for
  Transferring)
• Bathing G(2)(A) To meet this ADL, the
  individual must score a 1, 2, 3, 4, or 8 as
  described below
• (0) Independent No help provided.
• (1) Supervision Oversight help only.
• (2) Physical Help Limited to Transfer Only.
• (3) Physical Help With Part of Bathing Activity.
• (4) Total Dependence.
• (8) Activity Did Not Occur During the Entire
  7-Day Period (See definition under transferring)

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Definitions to be Applied When Completing MDS
ADLs cont..

• Bladder Continence H(1)(b) In order to meet
  this ADL, the individual must score a 2, 3, or 4
  in this category
• (0) Continent Complete control.
• (1) Usually Continent incontinent episodes once
  a week or less.
• (2) Occasionally Incontinent 2 times a week but
  not daily.
• (3) Frequently Incontinent Tended to be
  incontinent daily, but some control present
  (e.g., on day shift).

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Definitions to be Applied When Completing MDS
ADLs cont..

• Bladder Continence H(1)(b) In order to meet
  this ADL, the individual must score a 2, 3, or 4
  in this category
• (4) Incontinent Had inadequate control multiple
  daily episodes.
• OR
• To meet this ADL, one of the following is
  checked
• H(3)(c) - External catheter.
• H(3)(d) - In-dwelling catheter.

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Definitions to be Applied When Completing MDS
ADLs cont..

• Bowel Continence H(1)(a) In order to meet
  this ADL, the individual must score a 2, 3, or 4
  in this category
• (0) Continent Complete control.
• (1) Usually Continent Control problems less than
  weekly.
• (2) Occasionally Incontinent Once a week.

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Definitions to be Applied When Completing MDS
ADLs cont..

• Bowel Continence H(1)(a) In order to meet
  this ADL, the individual must score a 2, 3, or 4
  in this category
• (3) Frequently Incontinent 2-3 times a week.
• (4) Incontinent Had inadequate control all (or
  almost all) of the time.
• OR
• To meet this ADL, H(3)(i) - Ostomy, is checked.

22
Definitions to be Applied When Completing MDS
Joint Motion cont..

• Joint Motion In order to meet this category, at
  least one of the following must be CHECKED
• Contracture to arms, legs, shoulders, or hands.
• Hemiplegia/hemiparesis.
• Quadriplegia.
• Arm partial or total loss of voluntary movement.
• Hand lack of dexterity (e.g., problem using
  toothbrush or adjusting hearing aid).
• Leg partial or total loss of voluntary movement.
  7. (i) Leg unsteady gait.
• Trunk partial or total loss of ability to
  position, balance, or turn body.

23
Definitions to be Applied When Completing MDS
Locomotion cont..

• C. Locomotion G(1)(f)(A) In order to meet
  this ADL, the individual must score a 1, 2, 3, 4,
  or 8 in this category (definitions are the same
  as described for Transferring)

24
Definitions to be Applied When Completing MDS
Behavior and Orientation cont..

• Behavior and Orientation In order to meet this
  category, the individual must meet at least one
  of the categories for both behavior AND
  orientation.

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Definitions to be Applied When Completing MDS
Behavior and Orientation cont..

• Behavior To meet the criteria for behavior, the
  individual must meet at least one of the
  following
• a. E(2)(e) Failure to eat or take medications,
  withdrawal from Self Care or leisure activities
  (must be CHECKED).
• OR
• b. One of the following is coded 1 (behavior of
  this type occurred less than daily) or 2
  (behavior of this type occurred daily or more
  frequently)
• E(4)(a)(A) - Wandering (moved with no rational
  purpose, seemingly oblivious to needs or safety).
  

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Definitions to be Applied When Completing MDS
Behavior and Orientation cont..

• b. One of the following is coded 1 (behavior of
  this type occurred less than daily) or 2
  (behavior of this type occurred daily or more
  frequently)
• E(4)(b)(A) - Verbally abusive (others were
  threatened, screamed at, cursed at).
• E(4)(c)(A) - Physically abusive (others were
  hit, shoved, scratched, sexually abused).
• E(4)(d)(A) - Socially inappropriate/disruptive
  behavior (made disrupting sounds, noisy, screams,
  self-abusive acts, sexual behavior or disrobing
  in public, smeared/threw food/feces, hoarding,
  rummaged through others belongings).

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Definitions to be Applied When Completing MDS
Behavior and Orientation cont..

• Orientation To meet this category, the
  individual must meet at least one of the
  following
• B(3)(d) - Awareness that the individual is in a
  nursing facility is NOT CHECKED.
• B(3)(e) - None of the memory/recall ability
  items are recalled must be CHECKED. OR

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Definitions to be Applied When Completing MDS
Behavior and Orientation cont..

• Orientation To meet this category, the
  individual must meet at least one of the
  following
• B(4) - Cognitive skills for daily
  decision-making must be coded with a 2
  (moderately impaired decisions poor cue or
  supervision required) or 3 (severely impaired,
  never or rarely made decisions).

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What if a Resident No Longer Meets Criteria?

• What Does DMAS Do?

30
Change in Level of Care

• The Department of Medical Assistance Services
  shall conduct surveys of the assessments
  completed by nursing facilities to determine that
  services provided to the residents meet nursing
  facility criteria and that needed services are
  provided.

31
Change in Level of Care

• Nursing Facilities have the ultimate
  responsibility to ensure residents meet the
  established criteria for continued stay.
• Part of good discharge planning is looking at
  discharge options.
• If DMAS determines that a resident does not meet
  the criteria for continued stay in a nursing
  facility, a Change in Level of Care is initiated.

32
Documentation used for Change in Level of Care

• CHECKLIST FOR CHANGES IN LEVEL OF CARE
• The following information must be obtained in
  order for DMAS to write a change in level of care
  memorandum.
• Admission Fact Sheet
• In/Out Tracking sheets
• Physicians Orders - 60 Days
• Physicians Progress Notes - 3 months

33
Documentation used for Change in Level of Care
cont

• Team Care Plan
• Nursing PRN Notes - 3 months
• Nursing Adm. Assessment
• Nursing Monthly Summaries - 3 months
• Med./Treatment Sheets - 3 months
• Pharmacy Reviews - 3 months
• MDS/Qtly review - 1 year
• DMAS 96
• Admission UAI

34
Documentation used for Change in Level of Care
cont

• Social Services Progress Notes 4 quarters
• Activities Progress Notes 4 quarters
• Dietary Progress notes 4 quarters
• Therapy Evals and notes 4 quarters
• Psychological Eval and notes 4 quarters

35
Change in Level of Care Procedures

• DMAS uses the aforementioned documentation to
  generate a memo that is submitted to our Medical
  Director.
• If the Medical Support Unit agrees that nursing
  facility criteria is not met, a letter is sent to
  the recipient, and the facility. The letter
  includes information about appeal rights.

36
Change in Level of Care Procedures

• The facility is given thirty days to submit
  documentation from the physician that the
  resident continues to meet nursing facility
  criteria.
• If that documentation is not submitted, then the
  DMAS Medical Directors decision will stand.

37
Change in Level of Care Procedures

• A letter will be sent to the facility and
  concerned parties regarding the decision.
• Payment to the facility is stopped within 10 days
  following the final determination if the decision
  is upheld.

38
Change in Level of Care Procedures

• Once the final decision is made, the recipient
  will be given an opportunity to appeal the
  decision if it is his/her wish to do so.
• The recipient may be required to be responsible
  for payment to the facility during the
  recipients appeal if the decision is upheld and
  they must be discharged.
• It is important that the facility has systems in
  place to identify those residents who do not meet
  the criteria for continued nursing facility stay.

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Medically Necessary Private Room Rate Differential

• What if a Resident Needs One?
• What Does a Facility Do?

40
Medically Necessary Private Room Rate Differential

• The Virginia Medicaid Nursing Facility Provider
  Manual, Chapter IV, page 2 states the following
• Payment may be made for a private room or other
  accommodations more expensive than semi-private
  only when such accommodations are medically
  necessary.
• It further states that
• Private rooms will be considered necessary when
  the residents condition requires him/her to be
  isolated for his/her own health or that of
  others.

41
What Does This Mean?

• Medicaid will not pay for a private room just
• Because the family prefers a private room or..
• Because a resident sleeps better in a private
  room or
• Because the resident walks around and disturbs
  other residents or
• Because the facility is going up on its room
  rates and the family does not want to pay the
  difference.

42
Medically Necessary Private Room Rate Differential

• Even though a resident has a right to personal
  privacy related to accommodations, medical
  treatment, written and telephone communications,
  personal care, visits, and meetings of family and
  resident groups, Medicaid is not required to
  provide a private room for each resident.
• The Virginia Medicaid Nursing Facility Provider
  Manual, Chapter VII Residents Rights and
  Responsibilities, page 5

43
Medically Necessary Private Room Rate Differential

• One of the services that may be charged to a
  residents fund, (with resident approval) and if
  the resident has requested this in writing is the
  charge for a Private room, except when
  therapeutically required
• The Virginia Medicaid Nursing Facility Provider
  Manual, Chapter VII Residents Rights and
  Responsibilities, page 14

44
Procedure

• Reimbursement for private rooms will only be
  made when authorized by the Virginia Department
  of Medical Assistance Services (DMAS). A written
  request for private room reimbursement must be
  submitted.

45
Procedure cont.

• Submit written request to
• Department of Medical Assistance Services
• Division of Long-Term Care
• Program Administration Supervisor II
• 600 East Broad Street, 10th Floor
• Richmond, VA 23219

46
Procedure cont.

• The written request must include, at a minimum,
  the following
• 1. Medical justification (signed and dated by the
  physician) for a private room
• 2. A list of the facilitys rooms indicating
  which are private and which are semi-private and
  
• 3. The current charges for the semi-private and
  private rooms.

47
Procedure cont.

• There must be current medical record
  documentation to support physicians request.
• That may include progress notes, nursing notes,
  physicians orders, lab results etc.
• A letter from the physician simply listing the
  residents diagnoses will not suffice.

48
Procedure cont.

• Most of these requests deal with residents who
  require some type of isolation for the purposes
  of infection control.
• Once the information has been received.
• It is reviewed and additional information is
  requested if needed
• A recommendation is made by our division
• It is then forwarded to the Medical Support
  Division at DMAS where they agree or disagree
  with the recommendation.

49
Procedure cont.

• If approved,
• The information is submitted to our Fiscal
  Division where they determine the rate
  differential.
• A letter is sent to the facility to include
  instructions on how to receive the approved rate,
  the begin date and information regarding the end
  date. These approvals are not open ended.

50
Procedure cont.

• If denied,
• A letter relaying this information as well as the
  facilitys appeals rights is sent to the
  facility.
• The facility, not the family, has 30 days to
  appeal the decision.

51
What is PIRS?

• What Do I Do With It?
• Why Is It Required?

52
PIRS Submission

• Upon admission to a nursing facility, a DMAS-80
  or Patient Intensity Rating System (PIRS) form
  should be completed for every Medicaid recipient
  and forwarded to DMAS for processing. (Nursing
  Facility Manual, Chap VI, pages 5-9)
• This includes those individuals who are admitted
  as Medicare primary (or in what is normally
  referred to as a skilled stay).

53
PIRS Submission

• PIRS forms may be faxed to [phone] to
  DMAS. DMAS does not confirm receipt of faxes do
  to the shear volume of documents we receive each
  day.
• Please either FAX or mail the form not both.

54
PIRS Submission

• PIRS forms must be sent to DMAS for processing
  within 30 days or less of admission to the
  nursing facility.
• PIRS forms do not require the signature of the
  Nursing Facility Administrator.
• PIRS forms must contain the complete Medicaid 12
  digit Enrollee ID number for processing.
• DMAS cannot process any pending Medicaid
  eligibility requests.

55
PIRS Submission

• The National Provider Identifier Numbers are
  required for submitted PIRS forms.
• NPIs are 10 digits.
• Medicaid recipient numbers are 12 digits in
  length.
• Please submit the Medicaid Enrollee number and
  not the case number.

56
PIRS Submission

• DMAS will verify eligibility and enter the
  information from the PIRS form into the level of
  care file in the VaMMIS system.
• This generates an authorization to bill letter
  back to the provider.
• The provider may then bill for services.
• DMAS has 5 business days to complete processing.

57
Top Reasons for Return of PIRS Forms

• Medicaid Enrollee Number is Invalid
• Recipient has AID Category of 012, 032, or 052
• Recipient has AID Category of SLMB
• Recipient has AID Category of QMB
• Recipients Medicaid coverage has been cancelled
• DMAS notifications contain what appropriate
  action is necessary to correct the aid category
  problems.

58
Billing Level of Care Change Process - An Example

• An individual enters a nursing facility and DMAS
  issues a level 1 or Medicaid only authorization
  to bill.
• The individual then has a fall and is
  hospitalized.
• The individual has the required three day
  hospital stay and returns to the nursing facility
  as skilled or Medicare primary/Medicaid
  secondary.
• The nursing facility must then request a level
  change from a level 1 authorization to bill to a
  level 2 authorization to bill.

59
Billing Level of Care Change Process - An Example

• The nursing facility can fax in the information
  to DMAS and must include the begin date for the
  level 2 authorization.
• DMAS will process the request and a new
  authorization to bill letter will be generated
  with the proper begin date and provider number.
• The nursing facility must notify DMAS (via the
  same process) when the level 2 stay has ended and
  the individual is converting back to a level 1
  Medicaid only status.

60
Billing Level of Care Change Process

• Level changes should be clear, readable, and
  contain all necessary information for processing.
  
• Level change requests may be faxed to (804)
  371-4986.
• Level changes may be sent on a copy of the
  original request or on a fax cover sheet.

61
Discharge Information

• Please submit discharge information by using any
  of the outlined formats below
• DMAS-122
• MDS Discharge Tracking Form (preferred method
  NF Manual, Chap VI, pages 9-10
• Authorization Letter

62
MDS Quality Management Review (QMR)

• What is the Secret to a Successful MDS QMR?

63
MDS QMR

• The MDS is completed through discussions with all
  members of the interdisciplinary team, as well as
  the resident and/or their representative, for a
  holistic assessment.

64
MDS QMR

• Fill out every blank in the MDS
• Assure every i is dotted and t is crossed
• Your assessment and completion of the MDS
  determines your reimbursement rate

65
MDS QMR

• The MDS is complete, it has been submitted and
  youre going merrily along your way..

66
MDS QMR

• Then out of the blueMEDICAID appears to do the
  MDS QMR!

67
MDS QMR

• DO NOT PANIC!
• REMAIN CALM!
• THEY CAN SMELL FEAR!

68
MDS QMR

• Hundreds of blanks on the MDS have been
  completed, DMAS is reviewing only 104 elements.
• Of course we know you have all of the supporting
  documentation in the resident record to justify
  the score for each element.

69
MDS QMR

• DMAS will provide you a list of resident records
  to be reviewed.
• We will require all documentation that support
  the scores.
• This includes the current record and all records
  at least 30 days previous to the Assessment
  Reference Date.

70
MDS QMR

• Hopefully, that did not hurt too much.REMEMBER
  the secret to a successful MDS QMR???
• SUPPORTING DOCUMENTATION

71
Therapeutic Beds

• Who, What, Where, When and How?

72
Therapeutic Beds Cost Settlement

• Effective for services on or after July 1, 2005,
  NFs shall be reimbursed an additional 10 per day
  for those recipients who require a specialized
  treatment bed due to their having at least one
  stage IV pressure ulcer. Recipients must meet
  criteria as outlined in 12 VAC 30-60-350, and the
  additional reimbursement must be pre-authorized
  as provided in 12 VAC 30-60-40.

73
Therapeutic Beds Cost Settlement

• NFs shall not be eligible to receive this
  reimbursement for individuals whose services are
  reimbursed under the Specialized Care
  methodology. Effective July 1, 2005, this
  additional reimbursement shall be subject to
  adjustment for inflation in accordance with 12
  VAC 30-90-41B, except that the adjustment shall
  be made at the beginning of each state fiscal
  year, using the inflation factor that applies to
  provider years beginning at that time. This
  additional payment shall not be subject to direct
  or indirect ceilings and shall not be adjusted at
  year-end settlement.

74
Therapeutic Beds

• Prior approval by DMAS will be required for all
  therapeutic beds (Low air loss or Air Fluidized)
  furnished to nursing home residents who have a
  documented Stage IV pressure ulcer. (RAI MDS
  Classification Stage IV A full thickness of
  skin and subcutaneous tissue is lost, exposing
  muscle or bone)
• Residents enrolled in Specialized Care are not
  eligible for the 10 a day reimbursement for the
  therapeutic bed.

75
Therapeutic Beds

• The facility is required to submit via fax the
  DMAS-258 Specialized Treatment Bed
  Pre-Authorization Form to fax [phone].
• The reimbursement at 10 a day for the
  therapeutic bed will begin from the date of the
  physician order plus one day for up to 82
  consecutive days.
• Example
• Order received January 1, 2008
• Authorization valid through March 22, 2008

76
Therapeutic Beds

• A request for the bed may be made up to three
  times annually for a total of 246 days, if the
  following situations are met
• Annually - Based on the recipients first day of
  use of a bed
• The recipient has had a lapse of 30 days off the
  therapeutic bed
• The recipient has developed a new Stage IV ulcer.
  Facilities must report all Stage IV ulcers a
  patient has the first time a request for a
  therapeutic bed is made.

77
Therapeutic Beds

• You are required to resubmit your form if you
  receive a correction notification with the
  exception of the approval or duplicate requests
  which have been denied as duplicates.
• If you receive a denial you may request a
  reconsideration within 30-days of receiving
  notification by writing and sending supporting
  documentation to
• Supervisor LTC Division
• Department of Medical Assistance Services
• 600 East Broad Street, 10th Floor
• Richmond, Virginia 23219

78
Therapeutic Beds - QMR

• DMAS will conduct QMR of the use of the
  therapeutic specialty beds used by a NF in the
  treatment of recipients with Stage IV ulcers.
  These visits may be done in conjunction with the
  current Minimum Data Set (MDS) validation reviews
  currently conducted by the agency or be
  unannounced.

79
Therapeutic Beds QMR (cont)

• Documentation must be available and in the
  medical record that shows the following
• 1. A Physician order for the therapeutic bed
  dated and signed must be in the medical record.
• 2. The order must be for a low-air-loss or
  air-fluidized bed. Overlays are not covered under
  the 10-per-day reimbursement.

80
Therapeutic Beds QMR (cont)

• 3. Documentation must be in the medical record
  stating the recipient is on the bed and for how
  long.
• 4. Documentation must be noted on the Minimum
  Data Set (MDS) Form indicating a Stage IV
  pressure ulcer.
• Services not specifically documented in the
  recipients medical record as rendered shall be
  deemed as not rendered, and no reimbursement will
  be provided.

81
Long Term Care Bits and Pieces
82
LTC Resident Missing UAI

• You must have the required documentation prior to
  admitting an individual.
• If the UAI was not completed prior to admission
  and the individual extends their stay, the
  facility must fax letter to the DMAS Supervisor
  explaining why the facility accepted an
  individual without the required UAI.
• The letter must be accompanied by the completed
  DMAS-80 form.

83
Long Term Care-Bits Pieces

• Please remember to submit discharge information
  to DMAS for those residents who are discharged
  from your facility.
• If you have billing questions, call the PROVIDER
  HELPLINE _at_ 1-800-552-8627. The LTC Division is
  not able to answer billing questions.

84
Long Term Care-Bits Pieces

• Our mailing address is
• DMAS
• Division of Long-Term Care
• 600 East Broad Street, 10th Floor
• Richmond, Virginia 23219
• [phone]
• (804 371-4986 (fax)
• Website www.dmas.virginia.gov

85
Nursing Facility Manual

• Please make sure you have read and are up to date
  on the current Nursing Facility Provider Manual.
• Many of the questions that you call DMAS for are
  addressed within the provider manual.
• You should pay specific attention to Chapters IV,
  V, and VI.
• The Manual is available at our website via the
  following link http//websrvr.dmas.virginia.gov/
  ProviderManuals/Default.aspx

86
The Future of Long-Term Care

• Envision a world that values age, a nation that
  embraces agea Commonwealth that honors age.