Part 39      SKILLED NURSING SERVICES

317:30-5-390.Home and Community-Based Services Waivers for adults with an intellectual disability or certain adults with related conditions

[Revised 06-25-12]
(a) Introduction to waiver services. Each Home and Community-Based Services (HCBS) Waiver that includes services for adults with an intellectual disability or certain adults with related conditions allows payment for home health care services as defined in the waiver approved by Centers for Medicare and Medicaid Services.
(1) Home health care services are skilled nursing services provided to a member by a registered nurse or a licensed practical nurse that include:
(A) direct nursing care;
(B) assessment and documentation of health changes;
(C) documentation of significant observations;
(D) maintenance of nursing plans of care;
(E) medication administration;
(F) training of the member's health care needs;
(G) preventive and health care procedures; and
(H) preparing, analyzing, and presenting nursing assessment information regarding the member.
(2) The first 36 visits provided by the home health care agency are covered by the Medicaid State Plan.
(b) Eligible providers. Skilled nursing services providers must enter into contractual agreements with the Oklahoma Health Care Authority to provide HCBS for adults with an intellectual disability or certain adults with related conditions.
(1) Individual providers must be currently licensed in Oklahoma as a:
(A) registered nurse; or
(B) licensed practical nurse.
(2) Agency providers must:
(A) have a current Medicaid HCBS home health care agency contract; or
(B) be certified by Oklahoma State Department of Health as a home health care agency.

317:30-5-391.Coverage for Skilled Nursing Services
[Revised 8-02-06]
(a) All Skilled Nursing Services must be ordered and prescribed by a physician, supported by a nursing plan of care, included in the individual plan as described in OAC 340:100-5-53 and reflected in the Plan of Care approved in accordance with OAC 340:100-3-33 and OAC 340:100-3-33.1. For purposes of this Section, a physician is defined as all licensed medical and osteopathic physicians, physician assistants and advanced practice nurses in accordance with the rules and regulations covering the OHCA's medical care program. Arrangements for waiver Skilled Nursing Services are made through the personal support team with the specific involvement of the assigned Developmental Disabilities Services Division (DDSD) registered nurse (RN). The DDSD RN develops a nursing service support plan subject to review and authorization by the DDSD state nursing director or designee.
(b) Skilled Nursing Services are rendered in such a manner as to provide the service recipient as much autonomy as possible.
(1) Skilled Nursing Services must be flexible and responsive to changes in the service recipient's needs.
(2) Providers are expected to participate in annual personal support team meetings and other team meetings as required.
(3) Appropriate supervision of Skilled Nursing Services including services provided by licensed practical nurses (LPNs) is provided pursuant to State law and regulatory board requirements.
(4) Individual service providers must be RNs or LPNs currently licensed to practice in the State of Oklahoma.

317:30-5-392.Description of Skilled Nursing services
[Revised 8-02-06]
Types of Skilled Nursing Services in the waiver programs offered by the Oklahoma Department of Human Services' Developmental Disabilities Services Division (DDSD) are:
(1) Extended Duty Skilled Nursing Care. Extended Duty Skilled Nursing Care allows a licensed nurse to provide direct services in a community setting up to 24 hours per day.
(A) Extended Duty Skilled Nursing Care must be:
(i) provided only to those service recipients who have health-related issues that require skilled treatment or other intervention by a licensed nurse more frequently than every two hours;
(ii) ordered by a licensed medical physician, osteopathic physician, physician assistant, or advanced practice nurse;
(iii) justified in amount by the review done in accordance with OAC 340:100-5-26; and
(iv) documented in the service recipient's Plan of Care.
(B) When Extended Duty Skilled Nursing Care is medically indicated in accordance with subparagraph (A) of this paragraph, Extended Duty Skilled Nursing Care includes:
(i) skilled nursing care and interventions rendered directly to the service recipient by the nurse;
(ii) monitoring, evaluation, and documentation of the service recipient's physical or mental status;
(iii) administration of medication or treatments or both as ordered by the licensed medical physician, osteopathic physician, physician assistant or advanced practice nurse;
(iv) documentation of medication or treatment administration, skilled nursing interventions, service recipients's responses to medication or treatment, and any adverse reactions, or other significant changes;
(v) implementation of all tasks and objectives of the written nursing plan of care; and
(vi) performance of training and general care to the service recipient during periods in which skilled nursing tasks and interventions are not being performed.
(2) Intermittent Skilled Nursing Care. Intermittent Skilled Nursing Care involves performance of intermittent skilled tasks or interventions that only a licensed nurse can perform according to Section 1020 of Title 57 of the Oklahoma Statutes and OAC 340:100-5-26.3.
(A) Intermittent Skilled Nursing Care must be:
(i) ordered by a licensed medical physician, osteopathic physician, physician assistant or advanced practice nurse;
(ii) justified in amount by the review done in accordance with OAC 340:100-5-26; and
(iii) documented in the service recipient's Plan of Care.
(B) Intermittent Skilled Nursing Care includes:
(i) skilled nursing care and interventions rendered directly to the service recipient, as ordered by the licensed medical physician, osteopathic physician, physician assistant, or advanced practice nurse;
(ii) health-related assessments;
(iii) administration of medication or treatments ordered by the licensed medical physician, osteopathic physician, physician assistant, or advanced practice nurse;
(iv) documentation of medication or treatment administration, the service recipient's response to medication or treatment, and any adverse reaction or other significant changes; and
(v) implementation of all tasks and objectives of the nursing plan of care.
(3) Individualized Skilled Nurse Training and Evaluation. Individualized Skilled Nurse Training and Evaluation provides individualized evaluation and oversight of health care needs by a licensed nurse and specific, individualized health training by a licensed nurse to the service recipient or the service recipient's family or paid caregivers in accordance with Section 1020 of Title 56 of the Oklahoma Statutes and OAC 340:100-5-26.3.
(A) The licensed nurse assesses the service recipient's training needs prior to initiating competency-based training and develops a nursing plan of care that outlines the methods, goals, and objectives of the training to be performed. The nurse exercises prudent judgment in making the final decision as to what may be trained and delegated to community service workers, as provided by Section 1020 of Title 56 of the Oklahoma Statutes.
(B) Services include:
(i) individualized nurse training or evaluation or both provided directly to the service recipient, family or paid caregiver(s), as identified in the individual plan and the nursing plan of care;
(ii) evaluation and documentation of the competency of individuals trained through return demonstration, written test, verbalization of understanding, or other means suitable to the type of training performed;
(iii) professional monitoring and supervision to the community service worker in accordance with the applicable licensing requirements and evaluation of:
(I) the stability of the condition of the service recipient;
(II) the training and capability of the person receiving training;
(III) the nature of the task being trained; and
(IV) the proximity and availability of the licensed nurse to the person when the task is being performed; and
(iv) attendance at required meetings as specified in the individual plan.

317:30-5-393.Coverage limitations for Skilled Nursing Services
[Revised 8-02-06]
(a) Extended Duty Skilled Nursing Care cannot exceed three eight-hour shifts in a 24-hour period.
(b) Intermittent Skilled Nursing Care is limited to no more than three skilled task site visits in a 24-hour period of time.
(c) Individualized Skilled Nurse Training and Evaluation is reimbursed on the basis of a 15-minute unit of service. No more than 16 units of Individualized Skilled Nurse Training and Evaluation can be provided per month, unless the exception is:
(1) justified in writing by the team in accordance with OAC 340:100-3-33.1;
(2) recommended by the DDSD area nurse manager; and
(3) meets the requirements of OAC 340:100-3-33.1.

317:30-5-394.Diagnosis codes [REVOKED]
[Revoked 07-01-13]

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.