Indiana Administrative Code
Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES
Article 1 - MEDICAID PROVIDERS AND SERVICES
Rule 3 - Criteria for Level of Care in Long Term Care Facilities
Section 3-1 - Skilled nursing services; unskilled services

(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:

(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:

(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.