Skilled Respite Care Record - DMAS-90A Form

Submit the completed DMAS-90A form to DMAS by mail to 600 East Broad Street, Suite 1300, Richmond, VA 23219. You can also fax the form to (804) 786-1465. Ensure all required fields are completed and signed before submission. For assistance, contact the Waiver Services Unit at (804) 786-1465.

Ensure to submit the completed DMAS-90A form promptly for each care session provided in 2024 and 2025 to maintain compliance with regulations.

The DMAS-90A form is essential for documenting skilled respite care provided to Medicaid recipients. It ensures that all aspects of care, from neurological assessments to medication administration, are accurately recorded. Proper completion of this form aids in compliance with state and federal regulations, and facilitates smooth communication between caregivers, healthcare providers, and state authorities.

• 1. Recipient's Name: The full name of the Medicaid recipient receiving care.
• 2. Provider Name: The name of the RN/LPN or agency providing the care.
• 3. Medicaid ID: The Medicaid identification number of the recipient.
• 4. Provider ID: The identification number of the care provider.
• 5. Reason for Skilled Respite: The specific reason why skilled respite care is being provided.
• 6. Date: The complete date (month/day/year) of each care session.
• 7. Neurological Assessment: Assessment of the recipient's level of consciousness and orientation.
• 8. Cardiac Assessment: Auscultation of apical pulse, rhythm, presence of murmurs, and palpation of pulses.
• 9. Respiratory Assessment: Assessment of respiration rate, breath sounds, secretions, and trach care.
• 10. Monitors: Documentation of any monitors in use, including settings and oxygen levels.
• 11. Gastrointestinal Assessment: Assessment of abdomen, bowel sounds, tube feedings, and TPN.
• 12. Genitourinary Assessment: Documentation of voiding patterns and catheter care.
• 13. Other Care Provided: Details of baths, oral care, skin care, and wound care.
• 14. Medication: Documentation of medications administered and their tolerance.
• 15. Need for POC Changes: Assessment of the Plan of Care and any necessary changes.
• 16. New MD Orders: Documentation of any new medical orders from the doctor.
• 17. Time In: The time the caregiver arrived at the recipient's home.
• 18. Time Out: The time the caregiver left the recipient's home.
• 19. Number of Hours: The total number of hours of care provided.
• 20. Comments: Additional notes, including new doctor orders and any concerns.
• 21. Weekly Signatures: Signatures of the recipient/family and caregiver confirming the services provided.
• 22. RN/LPN Signature: Signature of the RN/LPN providing the care.
• 23. Print RN/LPN Name: Printed name of the RN/LPN providing the care.

Failure to submit the DMAS-90A form can result in non-compliance with regulations and potential issues with care documentation.

• Non-Compliance: Not submitting the form may lead to non-compliance with state and federal regulations.
• Inaccurate Records: Care provided may not be accurately documented, leading to potential issues in patient care.
• Audit Issues: State authorities may have concerns during audits if proper documentation is not provided.

• 1. Skilled Respite Care: Documenting skilled respite care provided by RN/LPN.
• 2. Medical Assessments: Recording neurological, cardiac, respiratory, gastrointestinal, and genitourinary assessments.
• 3. Care Provided: Detailing all other care provided, including baths, oral care, skin care, and medications.
• 4. Plan of Care: Assessing the Plan of Care and documenting any necessary changes.
• 5. New MD Orders: Recording any new medical orders from the doctor during the care session.