D.C. Mun. Regs. tit. 29, r. 29-1931

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-1931 - SKILLED NURSING SERVICES

1931.1

The purpose of this section is to establish standards governing Medicaid eligibility for skilled nursing services under the Home and Community-Based Services Waiver for Individuals with Intellectual and Developmental Disabilities (Waiver) and to establish conditions of participation for providers of skilled nursing services.

1931.2

Skilled nursing services are medical and educational services that address healthcare needs related to prevention and primary healthcare activities. These services include health assessments and treatment, health related trainings and education for persons receiving Waiver services and their caregivers.

1931.3

To be eligible for Medicaid reimbursement, the person shall first exhaust all available skilled nursing visits provided under the State Plan for Medical Assistance (Medicaid State Plan) prior to receiving skilled nursing services under the Waiver.

1931.4

To be eligible for Medicaid reimbursement, the person shall have a condition of circulatory or respiratory function complications, gastrointestinal complications, neurological function complications, or the existence of another severe medical condition that requires monitoring or care at least every other hour.

1931.5

To be eligible for Medicaid reimbursement, skilled nursing services shall:

(a) Be ordered by a physician when it is reasonable and necessary to the treatment of the person's illness or injury, and include a letter of medical necessity, a summary of the person's medical history and the duties that the skilled nurse would perform and a skilled nurse checklist. A Prior Authorization Form - 719A from the Department of Health Care Finance will suffice as the physician's order in accordance with the requirements set forth in this section; and

(b) Be authorized in accordance with each person's ISP and Plan of Care after all Medicaid State Plan skilled nursing visits have been exhausted.

1931.6

The physician's order described in Subsection 1931.5 shall include the scope, frequency, and duration of skilled nursing services; shall be updated at least every ninety (90) calendar days; and shall be maintained in the person's records.

1931.7

In order to be eligible for Medicaid reimbursement, the duties of a registered nurse (RN) delivering skilled nursing services shall be consistent with the scope of practice standards for registered nurses set forth in § 5414 of Title 17 of the District of Columbia Municipal Regulations (DCMR). They may include, at a minimum, but are not limited to the following duties:

(a) Performing a nursing assessment in accordance with the Developmental Disabilities Administration's Health and Wellness Standards;

(b) Assisting in the development of the Health Care Management Plan (HCMP);

(c) Coordinating the person's care and referrals;

(d) Administering medications and treatment as prescribed by a legally authorized healthcare professional licensed in the District of Columbia or consistent with the requirements in the jurisdiction where services are provided;

(e) Administering medication or oversight of licensed medication administration personnel;

(f) Providing oversight and supervision to the licensed practical nurse (LPN), when delegating and assigning nursing interventions;

(g) Providing updates to Department on Disability Services (DDS) quarterly and more frequently as needed, if there are any changes to the person's needs or physician's order;

(h) Training the person, licensed practical nurse (LPN), family, caregivers, and any other individual, as needed; and

(i) Recording progress notes during each visit that meet standards of nursing care and include the following:

(1) Any unusual health or behavioral events or changes in status;

(2) Any matter requiring follow-up on the part of the service provider or DDS; and

(3) Clearly written records that contain a statement of the person's progress or lack of progress, medical conditions, functional losses, and treatment goals that demonstrate that the person's services are and continue to be reasonable and necessary.

(j) Submit summary notes at least quarterly and submit quarterly reports in accordance with the requirements in Section 1909 (Records and Confidentiality of Information) of Chapter 19 of Title 29 DCMR.

1931.8

In order to be eligible for Medicaid reimbursement, the duties of an LPN delivering skilled nursing services shall be consistent with the scope of practice standards for a licensed practical nurse set forth in Chapter 55 of Title 17 DCMR. They may include, at minimum, but are not limited to the following duties:

(a) Immediately reporting, any changes in the person's condition, to the supervising registered nurse;

(b) Providing wound care, tube feeding, diabetic care, and other treatment regimens prescribed by the physician; and

(c) Administering medications and treatment as prescribed by a legally authorized healthcare professional licensed in the District of Columbia. If services are provided in another jurisdiction, the services shall be consistent with that jurisdiction's requirements.

1931.9

Medicaid reimbursable skilled nursing services shall be provided by an RN or LPN under the supervision of an RN, in accordance with the standards governing delegation of nursing interventions set forth in Chapters 54 and 55 of Title 17 DCMR.

1931.10

In order to be eligible for Medicaid reimbursement, each person providing skilled nursing services shall be employed by a home health agency that has a current District of Columbia Medicaid Provider agreement authorizing the service provider to bill for skilled nursing services.

1931.11

In order to be eligible for Medicaid reimbursement, each home health agency providing skilled nursing services shall comply with Section 1904 (Provider Qualifications) and Section 1905 (Provider Enrollment Process) of Chapter 19 of Title 29 DCMR.

1931.12

To be eligible for Medicaid reimbursement, skilled nursing services shall have prior authorization from DDS.

1931.13

In order to be eligible for Medicaid reimbursement, the RN shall monitor and supervise the provision of services provided by the licensed practical nurse, including conducting a site visit at least once every thirty (30) days, or more frequently, if specified in the person's ISP.

1931.14

In order to be eligible for Medicaid reimbursement, each provider shall maintain records pursuant to the requirements described under Section 1908 (Reporting Requirements) and Section 1909 (Records and Confidentiality of Information) under Chapter 19 of Title 29 DCMR.

1931.15

In order to be eligible for Medicaid reimbursement, each home health agency providing skilled nursing services shall ensure that the LPN receives ongoing supervision and that the service provided is consistent with the person's ISP.

1931.16

Each skilled nursing provider shall review and evaluate skilled nursing services provided to each person, at least quarterly.

1931.17

The skilled nursing provider shall maintain a contingency plan that describes how skilled nursing will be provided when the scheduled nurse is unavailable; and, if the lack of immediate care poses a serious threat to the person's health and welfare, how the service will be provided when back-up staff are unavailable.

1931.18

Services shall only be authorized for Medicaid reimbursement in accordance with the following provider requirements:

(a) The person has exhausted all nursing visits allowable under the Medicaid State Plan;

(b) DDS provides a written service authorization before the commencement of services;

(c) The service name and home health agency delivering services must be identified in the ISP and Plan of Care;

(d) The ISP, Plan of Care, and Summary of Supports and Services documents the amount and frequency of services to be received; and

(e) Services shall not conflict with the service limitations described under Subsection 1931.20.

1931.19

Medicaid reimbursement for skilled nursing services is only available for individuals who live independently in their natural homes, and people who receive the following residential supports: Host Homes; Supported Living; and Supported Living with Transportation. Skilled nursing services shall not be available when provided with Residential Habilitation or when Supported Living or Supported Living with Transportation is billed using the rate that includes direct skilled nursing services.

1931.20

Medicaid reimbursement is not available under the Waiver for skilled nursing visits that exceed fifty-two (52) visits per person annually.

1931.21

Upon exhaustion of the hours available for skilled nursing services under the Medicaid State Plan, Medicaid reimbursement may be available for one-to-one extended skilled nursing services for twenty-four (24) hours a day, for up to three hundred and sixty-five (365) days, with prior approval from DDS, for persons on a ventilator or requiring frequent tracheal suctioning.

1931.22

Prior approval for one-to-one extended skilled nursing services shall be obtained from the Medicaid Waiver Supervisor or designated DDS staff person after submission of documentation demonstrating the need for the extended services.

1931.23

Medicaid reimbursement governing the provision of skilled nursing and extended skilled nursing services shall be based on whether the Waiver services are being delivered by an RN or an LPN under the supervision of an RN.

1931.24

The Medicaid reimbursement rate for skilled nursing services and extended skilled nursing services shall be fifteen dollars ($15.00) for each fifteen (15) minute unit of service for services provided by an RN, and twelve dollars and fifty cents ($12.50) for each fifteen (15) minute unit of service provided by an LPN. The Medicaid reimbursement rate for an initial assessment is a flat rate of one hundred and twenty dollars ($120.00). The initial assessment for skilled nursing services shall be used for new admissions and any significant health condition changes that may warrant changes in a person's supports and services. The Medicaid reimbursement rate for quarterly reassessments and supervisory visits shall be the RN rate for each fifteen (15) minute unit of service not to exceed a total of eight (8) units of service per reassessment or supervisory visit.

1931.25

A provider shall provide at least eight (8) minutes of service in a span of fifteen (15) continuous minutes to be able to bill a unit of service.

1931.26

Any future increases in the Medicaid reimbursement rate for skilled nursing services under the Medicaid State Plan, listed in Title 29 (Public Welfare) of the DCMR, shall be applied equally to skilled nursing services and extended skilled nursing services through the Waiver.

D.C. Mun. Regs. tit. 29, r. 29-1931

Final Rulemaking published at 61 DCR 2615 (March 28, 2014); amended by Final Rulemaking published at 62 DCR 15336 (11/27/2015); amended by Final Rulemaking published at 63 DCR 9676 (7/22/2016); amended by Final Rulemaking published at 69 DCR 10218 (8/12/2022)

Authority: An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02 (2012 Repl. & 2013 Supp.)), and Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2012 Repl.)).