Current through Register Vol. 47, No. 5, March 10, 2024
Intermediate nursing services in a licensed intermediate
health care facility are defined as those services furnished in an institution
or distinct part thereof to those clients who do not have an illness, disease,
injury, or other condition that requires the degree of care and treatment which
a hospital, Extended Care Facility, or Skilled Nursing Care Facility is
designed to provide. Such services are provided under the supervision of a
registered professional nurse or licensed practical nurse during the day shift,
seven (7) days per calendar week. Covered intermediate services will be at a
level less than those described as skilled nursing services and will include
guidance and assistance for each client in carrying out their personal health
program to assure that preventive measures, treatment, and medications
prescribed by the physician are properly carried out and recorded.
These services are provided for according to a plan of
treatment written by a physician licensed to practice medicine in the State of
Colorado, and apply to clients whose conditions require medical services to
maintain a degree of stability which has been achieved.
There must exist a medical need for the attending physician
to visit the client on a professional basis at least once in every calendar
quarter.
8.409.1
SEPARATION OF
SKILLED NURSING FACILITY PATIENTS FROM THOSE REQUIRING INTERMEDIATE CARE:
DISTINCT PART REQUIREMENT
All nursing facilities which provide both skilled nursing
facility care and care and services to clients classified as requiring
intermediate nursing care, shall set aside a distinct part, or identifiable
unit in such facility for the provision of such intermediate care to such
clients.
A "distinct part" is one that meets the following
conditions:
Identifiable unit- The distinct part of the nursing facility
is an entire unit such as an entire ward or contiguous wards, wing, floor, or
rooms. With respect to facilities having 2 or more rooms, such must be
contiguous. The identifiable unit must consist of all beds and related
facilities in the unit and house all patient-clients classified as intermediate
care clients for whom payment is being made, except as provided in paragraph
(d) below. It is clearly identified and is approved, in writing (licensed), by
CDPHE.
Staff- Appropriate personnel shall be assigned to the
identifiable unit and must work regularly therein. Immediate supervision of
staff shall be provided at all times by qualified personnel as required for
licensure.
Shared Facilities and Services- The identifiable unit may
share such control services and facilities as management services, dietary,
building maintenance and laundry, with other units.
Transfers Between Distinct Parts- Nothing herein shall be
construed to require transfer of a client within the nursing facility, when, in
the opinion of the client's physician, such transfer might be harmful to the
physical or mental health of the client. Such opinion of the physician must be
recorded on the patient's nursing facility medical chart and stand as a
continuing order unless the circumstances requiring such exception
change.
8.409.2
ORGANIZATION OF INTERMEDIATE NURSING SERVICE
The following nursing care services and organization must be
established as a minimum in order for an intermediate nursing care facility to
receive reimbursement:
1.
Administrative and supervisory responsibilities must be in writing.
2. Duties must be clearly defined in writing
and assigned for the staff members.
3. Written policies and procedures for client
care must be available to all personnel.
8.409.21
PROFESSIONAL PERSONNEL -
"DIRECTOR OF NURSING"
There must be on duty and in charge of the facility's nursing
activities either a registered professional nurse or a licensed practical nurse
who:
1. Is qualified by education,
training, or experience for supervisory duties;
2. Is responsible to the administrator for
development of standards, policies, and procedures governing intermediate
nursing care, and for assuring that such standards, policies and procedures are
observed;
3. Is responsible to the
administrator for the selection, assignment, and direction of the activities of
nursing service personnel;
4. Is
employed full time (40 hours per week) in the facility;
5. Is devoted, full-time to direction and
supervision of the nursing services; and
6. Is on duty during the day shift.
8.409.22
NURSING
PERSONNEL
For the two day shifts (16 hours per calendar week) not
covered by the Director of Nursing, there shall be a Registered Professional
Nurse or a licensed Practical Nurse, and:
1. There shall be, at all times, a
responsible staff member actively on duty in the facility, and immediately
accessible to all residents, to whom residents can report injuries, symptoms of
illness, or emergencies, and who is immediately responsible for assuring that
appropriate action is promptly taken.
2. Assistance as needed to clients with
routine activities of daily living including such services as help in bathing,
dressing, grooming, and management of personal affairs.
3. Continuous supervision for residents whose
mental condition is such that their personal safety requires such
supervision.
8.409.23
PROFESSIONAL PLANNING AND SUPERVISION OF MEAL SERVICE
At least three meals a day, constituting a nutritionally
adequate diet must be served in one or more dining areas separate from the
sleeping quarters. Tray service must be provided for clients temporarily unable
to leave their rooms.
If the facility accepts or retains clients in need of
medically prescribed special diets, the menus for such diets shall be planned
by a professionally qualified dietitian, or must be reviewed and approved by
the attending physician. The facility must provide supervision of the
preparation and serving of the meals and their acceptance by clients.
8.409.24
ANCILLARY
PERSONNEL
Authorized subsidiary personnel performing duties in support
of professional health care services include:
1. Nurse aides
2. Dietary
3. Housekeeping and maintenance
To assure the provision of adequate nursing services, each
intermediate nursing care facility must provide sufficient:
1. Numbers and categories of personnel, as
determined by the number of clients 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 regulations.
2. Nursing and auxiliary personnel are
employed and assigned to duties on the basis of their qualifications or
experience to perform designated duties.
3. Bedside care under direction of the
client's physician in the presence of minor illness and for temporary periods
to include nursing service provided by, or supervised by, a professional nurse
or licensed practical nurse.
An intermediate care facility may, at its option, secure the
services of a pharmacy consultant. If such facility takes this option, the
provisions of rule item 2 are applicable.
8.409.3
CLINICAL RECORDS
8.409.31
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. Pharmacy Consultant's
notes.
8.409.32
RETENTION OF RECORDS
1. Files
retained at least six (6) years. (Before destruction of records, however, the
nursing home's legal counsel should be consulted.)
2. In the event that a patient is transferred
to another health facility, certain transfer information should be incorporated
in a record to accompany the patient. This information should include:
a. A transfer form of diagnosis;
b. Aid to daily living information;
c. Transfer orders;
d. Nursing care plan;
e. Physician's orders for care.
8.409.33
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
home medical record with a copy to the county department) at the time of
admission. This form must be signed by the client, or the client's designated
representative, parent (if a minor), guardian, or other legally responsible
person.
8.409.34
RECORDS ADMINISTRATOR
It is recommended that the Intermediate Health Care Facility
have available:
1. A consultant who is
a registered records administrator, or a person who is accredited as a records
technician.
2. An employee who is
trained or is receiving training in medical records management for
accreditation as a records technician or a registered records
administrator.
8.409.4
MEDICAL BASIS FOR CARE -
INTERMEDIATE NURSING 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 functional need for such admission. The client's 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.
8.409.41
PHYSICIANS'
INVOLVEMENT
8.409.42
DETERMINATION FOR INTERMEDIATE NURSING CARE
The medical need of a client for Intermediate Nursing Care
shall be delineated in the plan of treatment and substantiating orders written
by the physician and by the performance of the necessary Intermediate nursing
services implementing such plans and orders.
Upon admission to an Intermediate 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
Intermediate 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 noninstitutional life. The plan
must be reviewed consistent with the continuing professional care by the
physician, 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 not exceed ninety (90) days unless reordered
in writing by the physician. Telephone orders may be accepted by licensed
nurses, but 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 quarter,
must be evidenced in the clinical record by a valid signed entry.
5.
Plan for Emergency
Care. Each Intermediate Nursing Care Facility must provide for
one, or more, physicians to be available to furnish emergency medical care, or
surgical procedures, 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. An RPN or LPN must be on call
(for availability to handle emergencies; to contact the physician, receive
orders or medications) for all shifts other than the day shift. The
Intermediate 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.
8.409.43
PHYSICIANS' INVOLVEMENT
REDETERMINATION FOR INTERMEDIATE NURSING CARE
The medical need of the client for Intermediate Nursing Care
shall be redetermined every six months or at the time of the physician's
required quarterly visit if the client's condition has changed.
The term "substantial change" does not encompass short-term
treatment regimens for temporary illness, adjustments to prescribed medications
when the frequency and dosage is not affected, or changes to be in effect for
less than a thirty (30) day period.
8.409.5
MEDICAL REVIEW AND MEDICAL
INSPECTION - INTERMEDIATE CARE NURSING CLIENTS
Medical review of the treatment of all clients in
intermediate nursing care facilities who are entitled to medical assistance
will be accomplished annually.
8.409.51
MEDICAL REVIEW
TEAM
8.409.52
COMPOSITION AND MEMBERSHIP REQUIREMENTS
The medical review team for intermediate nursing clients
shall be composed of one or more nurses and other appropriate health and social
service personnel as indicated and will function under the supervision of a
physician.
No member of the team may be employed by or have financial
interest in any nursing home. No physician member of a team may inspect the
care of patients for whom he is the attending physician.
8.409.53
FUNCTION - MEDICAL REVIEW AND
EVALUATION1. The medical treatment of
intermediate nursing facility clients entitled to medical assistance shall be
reviewed at least annually.
2.
Annual review consists of an evaluation of the treatment, utilizing the medical
record and physical 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 calendar quarter.
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. Review of
prescribed medications by the attending physician at least every ninety (90)
days during the necessary client visit.
e. Tests, or observations of clients,
indicated by their medication regimen have been made at appropriate times and
properly recorded.
f. Physician,
nurse, and other professional staff progress notes are made as required, and
appear to be consistent with observed condition of the client.
g. 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.
h. Client's need for any service not
available in, or actually being furnished by the particular facility, or
through arrangements with others.
i. 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.
8.409.54
REPORTS
1. Review reports of care in each facility
are submitted to the Department.
a. After
review copies are forwarded to:
1) The
intermediate care facility.
2) The
intermediate 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.
8.409.55
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
Intermediate Nursing Care Facility.
c. County department responsible for the
client.
2. Changes in
classification recommended will be made prior to the next billing
period.
8.409.56
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.
