New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 166 - LONG-TERM CARE SERVICES
Subchapter 2 - NURSING FACILITY SERVICES
Section 10:166-2.2 - Delivery of nursing services
Universal Citation: NJ Admin Code 10:166-2.2
Current through Register Vol. 56, No. 24, December 18, 2024
(a) The NF shall provide 24-hour nursing services in accordance with the Department's minimum licensing standards set forth by the Standards for Licensure of Long-Term Care Facilities, N.J.A.C. 8:39, incorporated herein by reference, employing the service-specific case mix system to classify recipients with similar care requirements and resource utilization. The NF shall provide nursing services by registered professional nurses, licensed practical nurses and nurses aides based on the total number of residents multiplied by 2.5 hours per day; plus the total number of residents receiving each of the following services, as more fully described at (f) below:
| 1. | Wound care | 0.75 hour per day |
| 2. | Tube feeding | 1.00 hour per day |
| 3. | Oxygen therapy | 0.75 hour per day |
| 4. | Tracheostomy | 1.25 hours per day |
| 5. | Intravenous therapy | 1.50 hours per day |
| 6. | Respiratory services | 1.25 hours per day |
| 7. | Head trauma stimulation; and advanced neuromuscular or orthopedic care | 1.50 hours per day |
(b) The NF level of nursing care means services provided to Medicaid beneficiaries who are chronically or sub-acutely ill and require care for these entities, disease sequela or related deficits.
(c) The NF level of nursing care shall incorporate the principles of nursing process, which consists of ongoing assessment of the beneficiary's health status for the purpose of planning, implementing and evaluating the individual's response to treatment.
1. In his or her capacity as coordinator of
the interdisciplinary team, the registered professional nurse, who has primary
responsibility for the beneficiary, shall perform, beginning on the day of
admission, a comprehensive assessment of the beneficiary to provide,
communicate and record within the MDS: baseline data of physiological and
psychological status; definition of functional strengths and limitations; and
determination of current and potential health care needs and service
requirements.
i. In addition to clinical
observations and hands-on examination of the Medicaid beneficiary, the licensed
nurse shall review the HSDP and any available transfer records. The assessment
data shall be coordinated by the registered professional nurse with oral or
written communication and assessments derived from other members of the
interdisciplinary team and shall be consistent with the medical plan of
treatment. The initial comprehensive assessment (MDS) shall be completed no
later than 14 days after admission and on an annual basis thereafter. If there
is a significant change in the beneficiary's status, the NF shall complete a
full comprehensive assessment involving the MDS. The registered professional
nurse shall analyze the data and utilize the resident assessment protocols
(RAPs), or other screening tools as provided by the CMS RAI for completing the
comprehensive assessment, to focus problem identification, structure the review
of assessment information and develop an interdisciplinary care plan that
documents specific interventions unique to the individual, which define service
requirements and facilitate the plan of treatment.
2. The interdisciplinary care plan shall
identify and document the beneficiary's problems and causative or contributing
factors and is derived from the comprehensive assessment. The plan shall be
coordinated and certified by the registered professional nurse with active
participation of the Medicaid beneficiary and/or significant other. The scope
of the plan shall be determined by the actual and anticipated needs of the
Medicaid beneficiary and shall include: physiological, psychological and
environmental factors; beneficiary/family education; and discharge planning.
The care plan shall be a documented, accessible record of individualized care
which reflects current standards of professional practice and includes:
i. Identified problems (needs) and
contributing factors;
ii. Specific
and measurable objectives (outcomes) which provide a standard for measurement
of care plan effectiveness;
iii.
The plan of care shall emphasize interventions which prevent deterioration,
maintain wellness and promote maximum rehabilitation; and
iv. The initial interdisciplinary care plan
shall be completed and implemented within 21 days of admission and shall be
reviewed regularly and revised as often as necessary, according to all
significant changes in a beneficiary's condition and to attainment of and/or
revisions in objectives as indicated. Review and appropriate revision shall be
done at least every three months and whenever the clinical status of the
beneficiary changes significantly or requires a change in service
provision.
3.
Implementation of the interdisciplinary care plan and delivery of nursing care
shall be documented within nursing progress (clinical) notes, which shall
establish a format for recording significant observations or interaction,
unusual events or responses, or a change in the Medicaid beneficiary's
condition, which requires a change in the scope of service delivery. Specific
reference shall be made to the beneficiary's reactions to medication and
treatments, rehabilitative therapies, additional nursing services in accordance
with N.J.A.C.
8:85-2.2(a), observation of
clinical signs and symptoms, and current physical, psychosocial and
environmental problems. Nursing entries shall be made as often as necessary,
based on the Medicaid beneficiary's condition and in accordance with the
standards of professional nursing practice.
4. Assessment review is the process of
ongoing evaluation of health service needs and delivery. Nursing actions shall
be analyzed for effectiveness of care plan implementation and achievement of
objectives. The registered professional nurse, along with the Medicaid
beneficiary and/or significant other, shall participate with the team in the
ongoing process of evaluation, reordering priorities, setting new objectives,
revision of plans for care and the redirection of service delivery.
i. The assessment review process shall be
conducted quarterly. Conclusions shall be documented on the MDS quarterly
review, and the interdisciplinary care plan shall be updated to provide a
comparison of the Medicaid beneficiary's previous and present health status,
and to outline changes in service delivery and nursing interventions. The
assessment review shall identify the effectiveness of, and the Medicaid
beneficiary's response to, therapeutic interventions, and, whenever possible,
the reason for any ineffectiveness in beneficiary
responses.
(d) Restorative nursing is a primary component in the NF level of nursing care. Restorative nursing addresses preventable deterioration and is directed toward assisting each beneficiary to attain the highest level of physical, mental, emotional, social and environmental functioning. Restorative nursing functions shall include:
1. Supervision, direction,
assistance, training or retraining in all phases of activities of daily living
to promote independence or growth, and to develop or restore function to the
extent the individual is able (bathing, dressing, toileting, transfers and
ambulation, continence, and feeding);
2. Discharge planning which focuses on
assessment of the caregiving potential of the resident, family or significant
other. The nurse shall, along with other members of the interdisciplinary team,
extend the assessment beyond the needs of the resident to include assessment of
the caregivers' ability to provide long-term care and their need for
information on normal growth, development or aging; care needs; medication and
treatment; home safety and the need for additional supports, both formal and
informal, in preparation for the resident's return to the community;
3. Proper positioning of the individual in
bed, wheelchair or other accommodation to prevent deformities and pressure
sores;
4. Program of bowel and
bladder retraining for incontinence, in accordance with the individual's
potential for restoration;
5. Range
of motion exercises, active and passive, as necessary;
6. Follow-up care as required for physical
therapy, occupational therapy and/or speech-language pathology
services;
7. Follow-up care as
required for uncomplicated plaster care; assistance with adjustment to and use
of prosthetic and/or orthotic devices;
8. Routine care and maintenance of ostomies
(that is, cleansing and appliance change and instruction for self
care);
9. Resident education
relative to health care, special diet, and, if ordered by the physician,
self-administration of medication;
10. Encouragement of resident participation
in, and monitoring resident response to, individual or group activities and
therapies for psychosocial maintenance and restoration; and
11. In a NF providing care to children, the
application of the principles of growth and development in planning,
implementing and evaluating care needs; consideration of the child's physical
and developmental functioning with respect to his/her need for recreational and
educational stimulation and growth; and application of behavior modification
techniques in the management of developmental and disability-related behavior
problems.
(e) The 2.5 hours of nursing care provided shall also include, but not be limited to, the following nursing procedures, therapies and activities:
1. Safe and appropriate administration of
medications;
2. Emergency care (for
example, oxygen, injections, resuscitation);
3. Observation, recording, interpretation and
reporting of vital signs, height and weight;
4. Intake and output recording, as clinically
indicated;
5. Catheter care
including intermittent or continuous bladder irrigations, intermittent
catheterizations, and use of other drainage catheters;
6. Preparations for laboratory procedures and
collection of laboratory specimens;
7. Telephone pacemaker or electrocardiogram
checks;
8. Terminal illness
management, when there is need for supportive services and intensive personal
care;
9. Heat or cold treatments as
ordered by the physician;
10. Risk
determination for pressure sores using a standardized assessment instrument and
implementation of necessary preventive measures as clinically indicated (for
example, mattress overlays or cushions, positioning schedule, range of motion,
nutrition support, skin care and skin checks);
11. Care of Stage I and II pressure sores, as
follows:
i. A Stage I pressure sore is an area
of redness which does not respond to local circulatory stimulation. It involves
the epidermis. No break in the skin is evident;
ii. A Stage II pressure sore is a partial
thickness, loss of skin layers with epidermis and possibly dermis involvement.
A shallow ulcer or blister appears, and the site is free of necrotic
tissue;
iii. An individual who
enters the NF without pressure sores should not develop them unless the
individual's condition demonstrates pressure sores were unavoidable. Treatment
of superficial skin tears, wounds, excoriations and lesions shall be included
in the 2.5 hours of care;
12. The long-term care of a simple stabilized
tracheostomy with minimal care and supervision by licensed staff;
13. Uncomplicated administration of
respiratory therapies requiring minimal staff assistance, direction, and
supervision;
14. Protection of
individuals through the appropriate use of universal precautions, in accordance
with Centers for Disease Control guidelines published in the Morbidity and
Mortality Weekly Report, volume 38, number 5-6 (Centers for Disease Control,
Atlanta, GA 30333);
15. Appropriate
use of restraints (physical and/or chemical), in accordance with the
physician's order and N.J.A.C. 8:39 licensure standards, and clinically
appropriate measures to guarantee the safety of individuals (for example, side
rails);
16. Observation,
supervision and recording of basic nutritional states for maintenance of
current health status and prevention of deficiencies;
17. Observation, supervision and instruction
concerning special dietary requirements during ongoing adjustment to treatment
regimen for diagnosed medical conditions;
18. Nursing treatment, observation and/or
direction of mental status impairment which necessitates nursing supervision
and intervention (for example, marked confusion and/or disorientation in one,
two, or three spheres (time, place and/or person), marked memory loss, severe
impairments in judgment); and
19.
Emotional support and counseling on an ongoing basis, and during adjustment to
impaired physical and mental states, including observation for changes in
affect and mood which may require special precautions and/or
therapies.
(f) Nursing services requiring additional nursing hours pursuant to (a)1 through 7 above, in excess of those services included in NF level of nursing care as that term is described in (b) through (e) above, are described at (f)1 through 7 below. An individual beneficiary may require one or more additional nursing services, however, each category of additional nursing service may only be counted once for each individual beneficiary.
1. Wound
care (0.75 hour per day), which includes, but is not limited to, ulcers, burns,
pressure sores, open surgical sites, fistulas, tube sites and tumor erosion
sites. In this category are Stage II pressure sores encompassing two or more
distinct lesions on separate anatomical sites, Stage III and Stage IV pressure
sores.
i. Tube site and surrounding skin
related to ostomy feeding is not to be counted as an additional nursing service
unless there are complicating factors such as: exudative, suppurative or
ulcerative inflammation which require specific physician prescribed
intervention provided by the licensed nurse beyond routine cleansing and
dressing.
ii. Stage III and Stage
IV are defined as follows:
(1) Stage III. The
wound extends through the epidermis and dermis into the subcutaneous fat and is
a full thickness wound. There may be inflammation, necrotic tissue, infection
and drainage and undermining sinus tract formation. The drainage can be
serosanguinous or purulent. The area is painful.
(2) Stage IV. The pressure wound extends
through the epidermis, dermis, and subcutaneous fat into fascia, muscle and/or
bone. Eschar, undermining, odor and profuse drainage may exist.
(3) Other wounds which may be categorized
under wound care as defined in (f)1 above include:
(A) Open wounds which are draining purulent
or colored exudate or which have a foul odor present and/or for which the
individual is receiving antibiotic therapy;
(B) Wounds with a drain or T-Tube;
(C) Wounds which require irrigation or
instillation of a sterile cleansing or medicated solution and/or packing with
sterile gauze;
(D) Recently
debrided ulcers;
(E) Wounds with
exposed internal vessels or a mass which may have a proclivity for hemorrhage
when dressing is changed (for example, post radical neck surgery, cancer of the
vulva);
(F) Open wounds, widespread
skin disease or complications following radiation therapy, or which result from
immune deficiencies or vascular insufficiencies; and
(G) Complicated post-operative wounds which
exhibit signs of infection, allergic reactions or an underlying medical
condition that affects healing.
2. Tube feeding (1.00 hour per day), which
includes nasogastric tubes, percutaneous feedings and the routine care of the
tube site and surrounding skin of the surgical gastrostomy, provided that all
non-invasive avenues to improve the nutritional status have been exhausted with
no improvement; NF staff shall document in the clinical record the non-invasive
measures provided, the individual's poor response and the medical condition for
which the feedings are ordered; and the feedings are providing the individual
with either 51 percent or more calories per day, or 26 to 50 percent calories
and 501 milliliters or more of enteral fluid intake per day.
i. Feeding tubes that do not meet the dietary
administration and nutritional support criteria as stated in (f)2i or ii above
are covered under NF level of nursing care and are not counted as an additional
nursing service.
3.
Oxygen therapy (0.75 hours per day), which includes the provision of episodic
oxygen therapy to increase the saturation of hemoglobin (Hb) without risking
oxygen toxicity in beneficiaries with airway obstructive conditions such as
asthma, chronic obstructive pulmonary disease or heart failure. The beneficiary
requires frequent, recurring, and ongoing pulse oximetry monitoring. The
licensed nurses assess lung function and the beneficiary's symptoms that
require intervention by the physician, physician assistant or advanced practice
nurse.
4. Tracheostomy (1.25 hours
per day), which includes:
i. New tracheostomy
sites;
ii. Complicated cases
involving either symptomatic infections or unstable respiratory functioning;
or
iii. Frequent, recurring, and
ongoing suctioning.
5.
Intravenous therapy (1.50 hours per day), which includes (b)5i, ii, or iii
below, provided that, when clinically indicated, intravenous medications are
appropriately and safely administered within prevailing medical protocols; and,
if intravenous therapy is for the purpose of hydration, NF staff shall document
in the clinical record all preventive measures and attempts to improve
hydration orally, and the individual's inadequate response.
i. The administration and maintenance of
clinically indicated therapies by the NF, as ordered by the physician, such as
total parenteral nutrition, clysis, hyperalimentation, and peritoneal
dialysis;
ii. The administration of
fluids or medications by the NF, as ordered by the physician, by means of lines
or ports such as central venous lines, Hickman/Broviac catheters, or heparin
locks and the flushing and dressing thereof; or
iii. The flushing and dressing of lines or
ports such as central venous lines, Hickman/Broviac catheters, or heparin
locks, by the NF, as ordered by the physician, for an identified treatment
purpose and usage timeframe.
6. Respiratory services (1.25 hours per day),
which includes the provision of respiratory services as to which the individual
is dependent upon licensed nursing staff to administer, such as positive
pressure breathing therapy, Bilevel Positive Airway Pressure (BiPAP),
Continuous Positive Airway Pressure (CPAP) or aerosol therapy. The use of
hand-held inhalation aerosol devices, commonly referred to as "puffers", is not
included in this add-on service.
7.
Head trauma stimulation; and advanced neuromuscular or orthopedic care (1.50
hours per day), as follows:
i. Care of head
trauma is directed toward individuals who are stable (have plateaued) and can
no longer benefit from a rehabilitative unit or unit for specialized care of
the injured head. Individuals shall have access to and periodic reviews by such
specialists as a neurologist, neuropsychologist, psychiatrist and vocational
rehabilitation specialist, in accordance with their clinical needs. There shall
also be contact with appropriate therapies, such as physical therapy,
speech-language pathology services and occupational therapy. The distinguishing
characteristic for add-on hours for head trauma is the necessity for ongoing
assessment and follow-up by licensed nursing personnel focusing on early
identification of complications, and implementation of appropriate nursing
interventions. Nursing protocols may be initiated which are specifically
designed to meet individual needs of head injured individuals. The nurse may
also supervise a coma stimulation program, when this need is identified by the
interdisciplinary team.
ii.
Advanced neuromuscular care needs will be identified by the physician for
individuals during an unstable episode or where there is advanced and
progressive deterioration in which the individual requires observation for
neurological complications, monitoring and administration of medications or
nursing interventions to stabilize the condition and prevent unnecessary
regression.
iii. Advanced
orthopedic care is the care of plastered body parts with a pre-existing
peripheral vascular or circulatory condition requiring observations for
complications and monitoring and administration of medication to control pain
and/or infection. Such care also involves additional measures to maintain
mobility; care of post-operative fracture and joint arthroplasty, during the
immediate subacute post-operative period involving proper alignment; teaching
and counseling and follow-up to therapeutic exercise and activity regimens.
Individuals in this group shall be identified by the physician as needing
advanced orthopedic care. If the requirement for advanced orthopedic care
exceeds 30 days, clinical need must be demonstrated and clearly documented by
the interdisciplinary team.
Disclaimer: These regulations may not be the most recent version. New Jersey 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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