Florida Administrative Code
59 - AGENCY FOR HEALTH CARE ADMINISTRATION
59G - Medicaid
Chapter 59G-4 - MEDICAID POLICY
Section 59G-4.290 - Skilled Services
Universal Citation: FL Admin Code R 59G-4.290
Current through Reg. 50, No. 187; September 24, 2024
(1) Purpose. This rule establishes the level of care criteria that must be met in order for nursing and rehabilitative services to qualify as skilled services under Medicaid.
(2) Definitions as used in this section.
(a) Continuous. The need for
24-hour care in a skilled nursing facility with professional nursing services
available.
(b) Direct supervision.
Performance of a procedure in the presence of professional personnel or their
presence in the facility during the time in which the procedure is being
performed.
(c) Licensed nursing
personnel. Registered professional or licensed practical nurses, currently
licensed by the State of Florida to practice as a registered nurse or licensed
practical nurse respectively.
(d)
Professional personnel. Florida licensed or certified physicians, registered
nurses, respiratory care practitioners/therapists, audiologists, physical,
occupational or speech therapists.
(e) Rehabilitative services. Individualized
services prescribed by a health care professional that are designed to restore
a recipient to self-sufficiency or to the highest attainable functional level
in the shortest possible time following an illness or injury.
(f) Skilled care recipient. A Medicaid
applicant or recipient who requires skilled nursing or skilled rehabilitative
services.
(3) Skilled Services Criteria.
(a) To be classified as
requiring skilled nursing or skilled rehabilitative services in the community
or in a nursing facility, the recipient must require the type of medical,
nursing or rehabilitative services specified in this subsection.
(b) Skilled Nursing. To be classified as
skilled nursing service, the service must meet all of the following conditions:
1. Ordered by and remain under the
supervision of a physician;
2.
Sufficiently medically complex to require supervision, assessment, planning, or
intervention by a registered nurse.
3. Required to be performed by, or under the
direct supervision of, a registered nurse or other health care professionals
for safe and effective performance;
4. Required on a daily basis;
5. Reasonable and necessary to the treatment
of a specific documented illness or injury; and,
6. Consistent with the nature and severity of
the individual's condition or the disease state or stage.
(c) Examples of services that qualify as
skilled nursing services:
1. Intravenous
medication or fluids.
2.
Intramuscular or subcutaneous injection and hypodermoclysis when:
a. Administered by licensed nursing personnel
at least 5 times weekly, excluding daily insulin administration; and,
b. Observation is necessary to
assess the recipient's response to treatment or to identify adverse
reactions.
3. Management
and monitoring medication regime on a daily basis:
a. For drugs whose dosage requirements may
rapidly change;
b. For drugs prone
to cause adverse reactions, severe side effects or unfavorable reactions; and,
c. For residents with unstable
conditions.
4. Levin tube
and gastrostomy feedings; excluding feedings performed by residents, family
members, or friends.
5.
Administration of medical gases, aerosolized medication or oxygen which is
started, monitored and regulated by professional staff.
6. Naso-pharyngeal and tracheotomy
aspiration, excluding tracheotomy care in self-care residents.
7. Insertion, replacement, and sterile
irrigation of catheters when:
a. Medically
necessary or required for reasons other than to maintain satisfactory catheter
functioning and dryness;
b. The
medical need is documented by the physician;
c. Continuous irrigation, frequent insertion,
special care or observation is required because of bleeding, infection,
obstruction, or heavy sediment formations; and,
d. Care of a recently inserted supra-pubic
catheter, inserted within 2-4 weeks, is required.
8. Colostomy and ileostomy care:
a. When medically necessary and required
during early postoperative period;
b. During the period of initial self-care
training, or
c. When complications
are present and documented in the medical record.
9. Treatment of decubitus ulcers when:
a. Deep or wide without necrotic
center;
b. Deep or wide with layers
of necrotic tissue, or
c. Infected
and draining.
10.
Treatment of widespread infected or draining skin disorders.
11. Application of dressings involving
prescription medication and aseptic techniques when documented as required on a
daily basis. Excludes simple dressings involving non-infected cases, simple
skin breaks, and healed postoperative incisions.
12. Heat treatments prescribed by a physician
as daily treatment for a specific condition.
13. Rehabilitation nursing procedures
required on a daily basis as necessary to restore functioning, including
teaching and adaptive aspects of nursing.
(4) Skilled Rehabilitative Services. To be classified as skilled rehabilitative services, the services must meet all of the following conditions:
(a) Ordered by and
remain under the supervision of a physician;
(b) Reasonable and necessary to the treatment
of a recent or presently existing illness or injury;
(c) Performed by a physical therapist,
occupational therapist, certified respiratory care
practitioner/therapist;
(d)
Required at least 5 days a week; and,
(e) Reviewed and reevaluated at least every
30 days by the physician and the physical, occupational therapist or
respiratory care practitioner/therapist.
(5) Examples of services that qualify as skilled rehabilitation services:
(a) Daily
services of a speech pathologist or audiologist when necessary for the
restoration of function in speech or hearing.
(b) Ongoing assessment of rehabilitation
potential and needs in accordance with rule
59G-4.320, F.A.C.
1. Such services must be provided as an
integral part of the management of the care plan; and,
2. Must include results of tests and
measurements of range of motion, strength, balance, coordination, endurance,
functional ability, physical capacities, perceptual deficits, speech and
language or hearing disorders.
(c) Therapeutic exercise or activities that,
because of the type of exercise employed or the condition of the recipient,
must be performed by or under the supervision of a qualified physical therapist
or occupational therapist to ensure the safety of the recipient and the
effectiveness of the treatment.
(d)
Gait evaluation and training when furnished in accordance with the treatment
plan and designed to restore function to a recipient whose ability to walk has
been impaired by neurological, muscular or skeletal abnormalities.
(e) Range of motion exercises that are part
of the active treatment for a specific disease state which has resulted in a
loss of, or restriction of, mobility as evidenced by a therapist's notes
showing the degree of motion lost and the degree to be restored.
(f) Maintenance therapy, when the specialized
knowledge, skills, and judgment of a qualified therapist are required to design
and implement a maintenance program based on an initial evaluation and periodic
assessment of the recipient's needs, and consistent with the recipient's
capacity and tolerance. For example, a recipient with Parkinson's disease who
has not been under a rehabilitative program may require the services of a
qualified therapist to determine the type of exercise that will contribute the
most to the maintenance of his present level of functioning.
(g) Ultrasound, short-wave and microwave
therapy by a qualified physical therapist.
(h) Hot pack, hydrocollator, infrared
treatments, paraffin baths, and whirlpool in cases in which the recipient's
condition is complicated by circulatory deficiency, areas of desensitization,
or complications, and the skills, knowledge and judgment of a qualified
physical therapist are required.
(i) Chest physiotherapy or augmentary airway
clearance techniques, maintain airway patency and lung
volume.
(6) Examples of services that qualify as either skilled nursing or skilled rehabilitative services:
(a) Ongoing involvement of
registered nurses or other professional personnel in the evaluation of the
total needs of a resident and management of the treatment plan.
(b) Continuous observation and monitoring for
complications, adverse reactions, or changes in the status of a recipient's
condition when required to identify and evaluate the individual's need for
modification of the treatment plan or institution of a critical medical
procedure.
(c) Ongoing teaching and
training activities that are required to teach a recipient or caregiver how to
manage the treatment regime or perform self care or treatment skills. This
service must be ordered by the physician and evidenced by a recent change in
the health status of the resident. Skilled teaching and training services must
be documented on at least a daily basis in the progress
notes.
(7) Medically fragile. To be classified as medically fragile, the applicant or recipient must be:
(a) Age birth through age 20 years
old;
(b) Require skilled nursing in
a nursing facility; and,
(c) Be
technologically dependent on apparatus or procedures to sustain life, or
require significantly more intense and continual professional nursing
supervision and intervention to sustain life and who, without the provision of
such continuous services and observation, is likely to
expire.
(8) Services shall be considered skilled in cases in which medically complex condition(s) or medically fragile condition(s) are documented by a physician, or when the instability of the recipient's condition requires frequent nursing intervention, observation and assessment of the recipient's status and response to care.
(9) The restorative or recovery potential of the individual shall not be a factor when determining the need for skilled services.
(10) To qualify for placement in a nursing facility, the applicant or recipient must require 24 hour observation and care and the constant availability of medical and nursing treatment and care, but not to the degree of care and services provided in a hospital.
(11) When determining whether nursing facility services are required, consideration shall be given to the individual's physical and mental condition, excluding individuals with functional psychoses, acute psychiatric illness or individuals requiring or receiving active psychiatric treatment, or who require 24-hour care for diagnostic evaluation and psychiatric treatment.
Rulemaking Authority 409.919 FS. Law Implemented 409.905(2), (5), (8), 409.906(11) FS.
New 1-1-77, Amended 8-29-77, Formerly 10C-7.32, Amended 6-22-86, Formerly 10C-7.032, Amended 2-21-95.
Disclaimer: These regulations may not be the most recent version. Florida may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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