D.C. Mun. Regs. tit. 29, r. 29-9031

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

Rule 29-9031 - SKILLED NURSING SERVICES

9031.1 The purpose of this section is to establish standards governing Medicaid eligibility for skilled nursing services under the IFS Waiver and to establish conditions of participation for providers of skilled nursing services.

9031.2 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. Skilled nursing services may be delivered in the home and/or in the community.

9031.3 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.

9031.4 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.

9031.5 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.

(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.

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.

9031.6

The physician's order described in § 9031.5 shall include the scope, frequency, and duration of skilled nursing services; shall be updated at least every sixty (60) calendar days; and shall be maintained in the person's records.

9031.7

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 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 9006 (Records and Confidentiality of Information) of Chapter 90 of Title 29 DCMR.

9031.8

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.

9031.9

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.

9031.10

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.

9031.11

In order to be eligible for Medicaid reimbursement, each home health agency providing skilled nursing services shall comply with Section 9010 (Provider Qualifications) and Section 9009 (Provider Enrollment Process) of Chapter 90 of Title 29 DCMR. All IFS Waiver providers of skilled nursing services must comply with all of the requirements for Medicaid State Plan skilled nursing providers.

9031.12

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

9031.13

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.

9031.14

In order to be eligible for Medicaid reimbursement, each provider shall maintain records pursuant to the requirements described under Section 9013 (Reporting Requirements) and Section 9006 (Records and Confidentiality of Information) under Chapter 90 of Title 29 DCMR.

9031.15

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.

9031.16

Each skilled nursing provider shall review and evaluate skilled nursing services provided to each person, at least every sixty (60) days.

9031.17

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.

9031.18

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 § 9031.

9031.19

Upon exhaustion of the number of hours available for skilled nursing services under the Medicaid State Plan, Medicaid reimbursement may be available for additional skilled nursing services based upon medical need when required to support a person to live in the community, for persons who would otherwise be required to live in a nursing facility.

9031.20

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.

9031.21

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.

9031.22

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.

9031.23

The Medicaid reimbursement rates for skilled nursing services and extended skilled nursing services shall be the same as the rates for skilled nursing services under the Medicaid State Plan as set forth in the Medicaid fee schedule. The Medicaid reimbursement rate for an initial assessment is a flat fee rate. 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.

9031.24

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. 29-9031

Final Rulemaking published at 69 DCR 10229 (8/12/2022)