Current through Register Vol. 47, No. 5, March 10, 2024
A. Skilled
nursing services in a licensed nursing care facility are those services
performed by licensed nursing personnel, or personnel under their supervision.
These services must be performed according to a plan of treatment written by a
physician licensed to practice medicine in the State of Colorado. These
services apply to clients whose condition(s) require medical services to
maintain a degree of stability, which has been achieved. Components of these
services include:
1. The medical need for the
attending physician to visit the client on a professional basis at least once
every thirty (30) days.
2.
Observation and assessment of the total needs of the client, utilizing skilled
nursing judgment.
3. Planning,
organizing, and managing the client care plan which requires specialized
training to accomplish delivery of health care, or to attain the desired
results or to render direct services to "the patient".
B. These health care services require regular
medical care and 24-hour licensed nursing services for illnesses, injury, or
disability. Nursing service shall be organized and maintained to provide 24hour
licensed nursing services under the direction of a registered professional
nurse employed full time and at least two (2) hours total nursing staff time
for each patient per 24-hour day.
C. Covered skilled nursing services must
adhere to one or more of the following principles:
1. A service which requires a substantial
specialized judgment and skill based on knowledge and application of the
principles of biological, physical, and social sciences, necessary to perform
or supervise effectively the services rendered, or
2. A service that is unskilled but which
requires skilled performance, supervision, or observation because of special
medical complications. Medical complications and special services must be
documented by the physician's order and the nursing notes.
D. In addition to meeting the definition of
skilled nursing services, coverage of such services is warranted only if
skilled nursing personnel must be available on a continuous 24-hour basis. In
determining whether the continuous availability of such personnel is warranted,
the following principles apply:
1.
Frequency of Services- The frequency of skilled
nursing services required, rather than their regularity, is the controlling
factor in determining whether the continuous availability of skilled nursing
personnel is warranted.
2.
Observation- Where observation is the principle
continuous service provided, because symptoms exist that indicate the need for
immediate modification of treatment of institution of medical
procedures.
E. The
purpose of the above-stated components and principles, and of
10 CCR
2505-10 section 8.408.1 et seq., is to provide general
direction and guidelines for admission, utilization review, and medical review;
with the intent that the individual's overall medical
situation (including mental condition) shall be taken into account
in evaluation and determination of the level of care to be provided.
8.408.1
SPECIFIC SERVICES WHICH ARE
SKILLED
Based upon the principles set forth, skilled nursing services
include but are not limited to the following:
A. Subcutaneous or intramuscular injections
and intravenous medications and/or feedings.
B. Levine tube and gastrostomy
feedings.
C. Naso-pharyngeal
aspiration.
D. Insertion and
replacement of catheters.
E.
Aseptic application of dressings involving prescription medications.
8.408.2
SPECIFIC SERVICES
WHICH ARE SUPPORTIVE
Supportive services which can be learned and performed by the
average non-medical person who has been trained in these procedures, provided
to either skilled or intermediate care patients include but are not limited to
the following:
A. Provision of routine
maintenance medications.
B. Prevent
decubiti, keep clean, and comfortable.
C. Safety measures against accident and
injury.
D. General maintenance are
of colostomy or ileostomy.
E.
Routine services in connection with in-dwelling bladder catheters.
F. Changes in dressings in noninfected
postoperative or chronic conditions.
G. Prophylactic and palliative skin care,
including bathing and application of creams, and care of minor skin
problems.
H. General methods of
caring for incontinent patients, including use of diapers.
I. General care of patients with a plaster
cast.
J. Routine care in connection
with braces and similar devices.
K.
Use of heat for palliative and comfort purposes.
L. Administration of medical gases after
initial phases of institution of therapy.
M. Assistance in dressing, eating, and going
to the toilet.
N. General
supervision of exercises which have been taught to the patient.
O. Diet supervision and administration for
those persons requiring specialized diet.
P. Skilled paramedical services involving
specialized training outside the licensed nursing curriculum.
8.408.3
ORGANIZATION OF SKILLED NURSING SERVICE
The following nursing care services and organization must be
established as a minimum in order for a skilled nursing care facility to
receive reimbursement.
A.
Administrative and supervisory responsibilities must be in writing.
B. Duties must be clearly defined in writing
and assigned for staff members.
C.
Written policies and procedures for client care must be available to all
personnel.
D. All professional
services rendered by the nursing facility staff, physician, or other
professional personnel, must be entered in the client's individual record and
signed.
8.408.4
PROFESSIONAL PERSONNEL
8.408.41
DIRECTOR OF NURSING
The nursing services must be under the direction of a
director of nursing service who:
1. Is
a registered professional nurse.
2.
Is qualified by education, training, or experience for supervisory
duties.
3. Is responsible to the
administrator for development of standards, policies, and procedures governing
skilled nursing care, and for assuring that such standards, policies, and
procedures are observed.
4. Is
responsible to the administrator for the selection assignment, and direction of
the activities of nursing services personnel.
5. Is employed full time in the
facility.
6. Devotes their full
time to direction and supervision of the nursing services; and,
7. Is on duty during the day shift.
8.408.42
CHARGE NURSE (RN OR
LPN)
At all times, there must be on duty and in charge of the
facility's nursing activities either:
1. A registered professional nurse;
or,
2. A practical (or vocational)
nurse who:
a. Is licensed by the State as a
practical (or vocational) nurse; and
b. Has graduated from a State-approved school
of practical nursing; or,
c. Has
other education and formal training that is found by the State authority
responsible for licensing of practical nurses to provide a background
considered to be equivalent to graduation from a State-approved school of
practical nursing.
8.408.43
NURSING PERSONNEL
Nursing personnel means registered nurse (RN), licensed
practical nurse (LPN), and those auxiliary workers, other than RN or LPN, in
the nursing service.
To assure the provision of adequate nursing services, each
nursing care facility must provide sufficient:
1. Numbers and categories of personnel as
determined by the number of patients in the facility and their particular
nursing care needs. This determination is made in accordance with accepted
policies of effective nursing care and with these guidelines will provide at
least two (2) hours total nursing staff time for each patient per 24-hour
day.
2. Nursing and auxiliary
personnel employed and assigned to duties on the basis of their qualifications
or experience to perform designated duties.
3. Amounts of nursing time to assure that
each patient:
a. Receives treatments,
medications, and diet as prescribed;
b. Is kept comfortable, clean, and
well-groomed;
c. Receives proper
care to prevent decubitus ulcers;
d. Is protected from accident and injury by
appropriate safety measures;
e. Is
encouraged to perform out-of-bed activities as permitted; and,
f. Receives assistance to maintain optimal
physical and mental function.
8.408.44
ANCILLARY PERSONNEL
Authorized subsidiary personnel performing duties in support
of professional health care services may or may not be included in arriving at
the computation of cost allowances set forth in
10 CCR
2505-10 section 8.400 et seq.
A. Dietary - Professional planning and
supervision of meal services.
Special and restricted diet files shall be maintained for
thirty (30) days, and any substitutions or variations noted. The patient's
reaction and acceptance of food must be observed and recorded.
Menus must be planned and supervised by professional
personnel meeting the following qualifications:
1. A dietician who meets the American
Dietetic Association's standards for qualification as a dietician;
or,
2. A graduate holding at least
a bachelor's degree from the university program, with major study in food or
nutrition; or,
3. A trained food
service supervisor, an associate degree dietary technician, or a professional
registered nurse, with frequent and regularly scheduled consultation from a
dietician or a nutritionist meeting the above-stated qualifications.
Inclusion of dietary consultation costs are an allowable item
in computing the rate of payment above-referenced.
B. Pharmacy Consultant- A person licensed to
practice pharmacy in the State of Colorado, and whose duties are related to the
nursing facility administration of drugs to patients. Such duties relate to:
1. Drug interactions;
2. Proper medication usage pertinent to the
diagnosis and length of medication; specific to proper usage in records, stop
orders, etc.;
3. Appropriate
storage and safeguards of medications;
4. Study of possible brand
interchanges;
5. Check on
authenticity of medication pursuant to labeling;
6. Contraindications and other professional
activities related to drug administration, receipting, storage, etc.
Costs related to pharmacal consultation are allowable in
determining the rate to be paid, under the same conditions as for dietary in
item 1 above.
C.
Housekeeping and Maintenance- Allowed pursuant to above-cited rules on cost
computation.
8.408.5
CLINICAL RECORDS
8.408.51
MAINTENANCE
The following records, as a minimum, must be kept current,
dated and signed, and must be made available for review if applicable:
1. Identification and summary
sheets.
2. Hospital discharge
summary sheet.
3. Medical
evaluation and treatment plan.
4.
Physician's orders.
5. Physician's
progress notes.
6. Nurse's progress
notes.
7. Medication and treatment
record.
8. Laboratory and X-ray
reports.
9. Consultation
reports.
10. Dental
reports.
11. Social Service
notes.
12. Pharmacal Consultant
records.
13. PASRR documentation to
include the Level I and Level II Reviews and the determination
letters.
8.408.52
RETENTION OF RECORDS1. Files
shall be retained for at least six years.
2. In the event that a client is transferred
to another health facility, certain transfer information should be incorporated
in a record to accompany the client. Such transfer information shall include:
a. Transfer form with diagnosis;
b. Aid to daily living information;
c. Transfer orders;
d. Nursing care plan;
e. Physician's orders for care.
8.408.53
CONFIDENTIALITY OF RECORDS
1.
Disclosed only to authorized persons.
2. Form APA-4, "Authorization for Release of
Medical Information" shall be executed in duplicate (original to the nursing
facility medical record with a copy to the County Department of Social/Human
Services) at the time of admission. This form must be signed by the client, the
client's designated representative, the client's parent (if a minor), guardian,
or other legally responsible person.
8.408.54
RECORDS ADMINISTRATOR
The nursing care facility must have available, and a staff
person designated:
a. A consultant or
full-time employee who is a registered records administrator (Medical Records
Librarian), or an accredited records technician, or;
b. A registered records administrator or
other employee who is trained in medical records, and who receives supervision
from a registered records administrator; or,
c. If the facility does not have such
employee with such training, an employee of the facility is assigned the
responsibility for assuring that records are maintained, completed, and
preserved. Such person, however, must be trained by, and receive regular
consultation from a registered records administrator or accredited records
technician.
8.408.6
MEDICAL BASIS FOR CARE -
SKILLED NURSING FACILITY CARE
Eligible clients may be admitted to approved facilities only
upon the certification of a physician licensed to practice in Colorado that
there is a medical need for such admission (Form ULTC-100). The clients'
freedom of choice of physician shall be respected. Health care of the client
must continue under the supervision of a physician. The facility must have a
physician available for necessary medical care in case of emergency.
8.408.61
PHYSICIANS'
INVOLVEMENT
8.408.62
DETERMINATION FOR SKILLED NURSING CARE
The medical need of a client for skilled nursing care shall
be delineated in the plan of treatment and substantiating orders written by the
physician and by the performance of the necessary skilled nursing services
implementing such plans and orders. Upon admission to a skilled nursing care
facility, the facility must obtain for the medical record of each such
client:
1. A summary of the course of
treatment by the attending physician or which was followed in the hospital, the
diagnosis(es) and current medical findings, and the rehabilitation
potential.
2. An evaluation by the
physician. Physical examination must be accomplished within 48 hours of
admission and recorded; unless such an examination has been accomplished within
five days prior to admission to the skilled nursing care facility.
3. Physician's orders. Orders must be written
for the immediate care of the client. These may be written by the attending
physician or by the physician who has the responsibility for emergency care in
this facility. The current hospital summary of the course of treatment, with
orders used, is acceptable as emergency orders.
4. The physician's treatment plan. The plan
must be written and must be directed towards maintaining the health status of
the client, preventing further deterioration of the physical well-being of the
client, and preparing the client for normal non-institutional life. The plan
must be reviewed and revised as necessary, and must include medication and
treatment orders which will be in effect for the specified number of days
indicated by the physician. This period shall be monthly unless reordered in
writing by the physician. Telephone orders may be accepted by licensed nurses
only and must be written into the clinical record by the receiving nurse. These
orders must be countersigned by the ordering physician within 48 hours.
The medical necessity for a physician's visit, at least once
every thirty (30) days, must be evidenced in the clinical record by a valid
signed entry.
5. Plan for
Emergency Care- Each skilled nursing care facility must provide for one, or
more, physicians to be available to furnish emergency medical care if the
attending physician is not immediately available. A schedule listing the name,
telephone number and days on call for a given physician will be posted at each
nursing station. The skilled nursing care facility must also establish
procedures which will be followed in the emergency care of the client, the
persons to be notified, and the reports to be prepared.
8.408.63
PHYSICIANS' INVOLVEMENT-
REDETERMINATION FOR SKILLED NURSING CARE
The medical need of the client for skilled nursing care shall
be redetermined monthly at the time of the physician's required monthly
visit.
The term "substantial change" does not encompass short-term
treatment regimens for temporary illness, adjustments to prescribed
medications, or changes to be in effect for less than a thirty (30) day
period.
8.408.7
MEDICAL REVIEW AND MEDICAL INSPECTION - SKILLED NURSING CLIENTS
Medical review of the treatment of all clients in skilled
nursing care facilities who are entitled to medical assistance will be
accomplished prior to May 2, 1972 (to meet requirements of
42 C.F.R. section
456.2), and annually thereafter. Medical
review procedures herein are in addition to those set forth in
10 CCR
2505-10 section 8.449 concerning Utilization
Review.
8.408.71
MEDICAL REVIEW
TEAM
8.408.72
COMPOSITION AND MEMBERSHIP REQUIREMENTS
The medical review team for skilled nursing care clients will
be led by a Colorado Registered Nurse or a Colorado Licensed Physician. The
teams will include other appropriate health and social service personnel.
Nurse-led teams will report to a physician.
No member of the team may be employed by or have financial
interest in any nursing facility. No physician member of a team may inspect the
care of clients for whom he is the attending physician.
8.408.73
FUNCTION - MEDICAL REVIEW AND
EVALUATION1. The medical treatment of
skilled nursing clients entitled to medical assistance shall be reviewed at
least annually.
2. Annual review
shall consist of an evaluation of the treatment, utilizing the medical record
and personal contact with, and observation of, each client in the nursing
facility surroundings. This review, at a minimum, will elicit:
a. Medical necessity for visit by attending
physician at least once every thirty (30) days.
b. Adequacy in quality and quantity as well
as the timeliness of treatment to meet health needs.
c. Adherence to the written physician's
treatment plan.
d. Tests, or
observations of clients, indicated by their medication regimen have been made
at appropriate times and properly recorded.
e. Physician, nurse, and other professional
staff progress notes are made as required, and appear to be consistent with
observed condition of the client.
f. Adequate services are being rendered to
each client as shown by such observations as cleanliness, absence of decubiti,
absence of signs of malnutrition or dehydration, and apparent maintenance of
optimal physical, mental, and psychosocial function.
g. Client's need for any service not
available in, or actually being furnished by the particular facility, or
through arrangements with others.
h. Each client actually needs continued
placement in the facility, or there is an appropriate plan to transfer the
client to an alternate method of care.
8.408.74
REPORTS
1. Review reports of care in each facility
are submitted to the Department.
a. After
review copies are forwarded to:
1) Nursing
care facility
2) Nursing care
facility Utilization Review Committee
3) CDPHE
2. Reports will cover observations,
conclusions and recommendations with respect to adequacy and quality of client
services in the facility, and of physician services to clients in the facility.
They will also cover specific findings with respect to individual clients and
any recommendations resulting therefrom.
8.408.75
STATE DEPARTMENT ACTION
1. Reports submitted as a result of Medical
Review may result in decisions to reclassify clients into a different level of
care, or recommendations for modification of treatment.
Such decisions or recommendations will be transmitted as
appropriate, to the:
a. Attending
physician.
b. Administration of the
nursing facility.
c. County
Department of Social/Human Services responsible for the client.
2. Changes in classification
recommended will be affected prior to the next billing period.
8.408.76
REVIEW OF STATE
DEPARTMENT ACTION
Disagreements with the decisions and recommendations of the
Review Team may be adjudicated through the Administrative Review mechanism of
the Department; however, the Department will retain the right to final
decision.
