Section 405 IAC 1-3-1 - Skilled nursing services; unskilled servicesAuthority: IC 12-15-1-1; IC 12-15-1-10
Affected: IC 12-15-5-1
Sec. 1.
(a) Skilled nursing services, as ordered by a physician, must be required and provided on a daily basis, essentially seven (7) days a week.(b) Rehabilitation services for an acute rehabilitative condition may be provided at either skilled or intermediate level of care, depending upon the resident's overall condition and nursing care needs. To qualify to skilled rehabilitation services, the following conditions shall be met:(1) The services are ordered by a physician and must be required and provided at least five (5) days a week.(2) The therapy must be of such complexity and sophistication that the judgment, knowledge, and skills of a licensed therapist are required.(3) The overall condition of the patient must be such that the judgment, knowledge, and skills of a licensed therapist are required.(c) If the patient's condition is such that it requires observation and assessment by licensed professional nursing staff to identify or evaluate the patient's need for modification of treatment and the initiation of additional medical procedures until the patient's condition is stabilized, the service is at the skilled level. These services must be documented by physician's orders, progress notes, and nurse's notes. Routine or prophylactic monitoring of a stable condition is considered intermediate level.(d) When licensed professional nursing staff is required to teach a skilled procedure in order to facilitate discharge to self-care, skilled level of care can be considered short term. This could include teaching self-injection, self-catheterization, catheter care, ostomy care, dressing changes, or suctioning. Nursing care plan and documentation of overall condition must substantiate that discharge to self-care following a training program is a realistic goal. Training programs of longer than thirty (30) days, when no other skilled services are required, will be considered appropriate for the intermediate level of care.(e) The development, management, and evaluation of a patient care plan, based on the physician's orders, constitute skilled nursing services when, in terms of the patient's physical or mental condition, these services require the involvement of skilled nursing personnel to meet the patient's medical needs, promote recovery, and ensure medical safety. However, the planning and management of a treatment plan and supervision of personal care does not in itself require skilled level of care. Skilled level of care is appropriate where the sum total of unskilled services that are a necessary part of the medical regimen, when considered in light of the patient's overall condition, makes the significant involvement of skilled nursing personnel necessary to promote the patient's recovery and medical safety. The need for significant skilled personnel involvement must be documented within the patient's medical record.(f) Based upon the principles in subsections (a) through (e), examples of skilled nursing services include, but are not limited to, the following: (1) Intravenous infusions or intravenous and intramuscular injections. However, injections which can usually be self-administered, such as the well-regulated diabetic who receives daily insulin injections, would not require skilled services. The occasional or PRN (as needed) intramuscular injection would qualify as a skilled service only if the patient's medical condition is unstable as supported by documentation in the patient's medical records.(2) Nasogastric tube and gastrostomy feedings.(3) Nasopharyngeal and tracheotomy aspiration. However, patients with tracheotomy tubes which have been used over a long period of time and where the patient is mentally able to perform this care with little, if any, supervision would not qualify for skilled level of care.(4) Insertion and sterile irrigation or replacement of catheters. Skilled care may be required for patients in whom catheter obstructions frequently occur necessitating the intervention of professional personnel. The sterile irrigation of catheters must be ordered by the physician specifying the type of irrigation and length of time which the sterile irrigations are to continue. Routine sterile irrigations continuing longer than fourteen (14) days will be considered appropriate for intermediate level of care.(5) Complex wound care involving sterile dressings, prescription medications, and aseptic techniques. Justification for these procedures must be fully documented, and the duration of these treatments must be specified by the physician. The necessity for the treatments continuing longer than thirty (30) days must be documented on the patient's record by fully describing the patient's condition.(6) Care of extensive decubitus ulcers. The size and stage of the decubitus must be documented. The treatment must be specifically ordered by the physician. Appropriate documentation to monitor the progress of the decubitus is also required.(7) Initial phases of a regimen involving administration of oxygen. Patients requiring the administration of oxygen on a daily basis for a new or recent medical condition would qualify for skilled level care. However, patients receiving oxygen either continuously or PRN for a chronic, stable medical condition would not qualify for skilled level care.(g) In order to qualify for skilled level of care, documentation of the medical necessity for increased intensity of nursing services must be noted in physician's orders, progress notes, and nurse's notes. When this intensity of nursing services is no longer required, it is the responsibility of the nursing facility and physician to transfer the resident to the intermediate level of care. The office may initiate an independent evaluation and level of care assessment to determine whether continued reimbursement at the skilled level is justified. Office of the Secretary of Family and Social Services; Long Term Care Facilities II; filed Feb 10, 1978, 11:20 a.m.: Rules and Regs. 1979, p. 269; filed Mar 15, 1988, 1:59 p.m.: 11 IR 2852; filed Mar 10, 1993, 5:00p.m.: 16 IR 1792; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFAReadopted filed 11/13/2019, 11:54 a.m.: 20191211-IR-405190487RFAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA Transferred from the Division of Family and Children (470 IAC 5-3-2) to the Office of the Secretary of Family and Social Services (405 IAC 1-3-1) by P.L. 9-1991, SECTION 131, effective January 1, 1992.