D.C. Mun. Regs. tit. 29, r. 29-9901

Current through Register Vol. 71, No. 44, November 1, 2024

Rule 29-9901 - SKILLED NURSING SERVICES

9901.1

Medicaid reimbursable Skilled Nursing services are part-time or intermittent skilled nursing care services that are needed by a beneficiary due to an illness or injury, and are furnished by nurses in accordance with the beneficiary's plan of care described in Subsection 9900.4.

9901.2

In order to be eligible for Medicaid reimbursement, a Home Care agency providing Skilled Nursing services shall meet the following requirements:

(a) Be enrolled as a Medicare Home Health Agency qualified to offer skilled nursing services as set forth in Sections 1861(o) and 1891(e) of the Social Security Act and 42 CFR Part 484;

(b) Have sufficient funds or "initial reserve operating funds" available for business expenses determined in accordance with federal special capitalization requirements for home care agencies participating in Medicare as set forth under 42 CFR § 489.28;

(c) Meet the District of Columbia Department of Health licensure requirements in accordance with Chapter 39 (Home Care Agencies) of Title 22-B DCMR;

(d) Be enrolled as a Medicaid provider of Home Health services and meet all requirements as set forth under Chapter 94 (Medicaid Provider and Supplier, Screening, Enrollment, and Termination) of Title 29 DCMR; and

(e) Have a surety bond, in accordance with federal requirements for home care agencies participating in Medicaid as set forth under 42 CFR § 441.16 and Subsection 9901.3.

9901.3

Except for government-operated Home Care Agencies, each Home Care Agency that is a Medicaid participating Home Care Agency or that seeks to become a Medicaid participating Home Care Agency shall:

(a) Obtain a fifty thousand dollar ($50,000) surety bond that meets the requirements as set forth under 42 CFR § 441.16; and

(b) Furnish a copy of the surety bond to DHCF.

9901.4

Medicaid reimbursable Skilled Nursing services shall be provided by a R.N. or licensed practical nurse (L.P.N.) licensed in accordance with the District of Columbia Health Occupations Revision Act of 1985, as amended, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201.01et seq.) and implementing rules.

9901.5

Medicaid-reimbursable Skilled Nursing services shall consist of the following duties:

(a) Conducting initial assessments either prior to service provision or at the onset of care and reassessments every sixty (60) calendar days thereafter to develop and update a plan of care;

(b) Coordinating the beneficiary's care and referrals among all Home Care agency providers;

(c) Implementing preventive and rehabilitative nursing procedures;

(d) Administering medications and treatments as prescribed by a licensed physician, pursuant to the District of Columbia Health Occupations Revision Act of 1985, as amended, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3 -1201 et seq.), as outlined under the plan of care;

(e) Recording progress notes at each visit and summary notes at least once every sixty (60) calendar days;

(f) Making necessary updates to the plan of care, and reporting any changes in the beneficiary's condition to his or her physician;

(g) Instructing the beneficiary on treatment regimens identified under the plan of care;

(h) Updating the physician on changes in the beneficiary's condition and obtaining orders to implement those changes; and

(i) For R.N.s who supervise nursing services delivered by a skilled nurse (R.N. or L.P.N.) and services delivered by Home Health Aides and Personal Care Aides, duties shall include, at minimum, the following:

(1) Supervising the beneficiary's skilled nurse and aide on-site, at least once every sixty (60) calendar days;

(2) Ensuring that new or revised physician orders have been obtained initially from the treating physician and then at least every sixty (60) calendar days thereafter, to promote continuity of care;

(3) Reviewing the beneficiary's plan of care, including ensuring integration of the Person-Centered Service Plan (PCSP) for EPD Waiver beneficiaries into the plan of care;

(4) Monitoring the beneficiary's general health outcomes, including taking vital signs, conducting a comprehensive physical examination, and determining mental status;

(5) Determining if the beneficiary has any unmet medical needs;

(6) Ensuring that all home health services are provided safely and in accordance with the plan of care;

(7) Ensuring that the beneficiary has received education on any needed services;

(8) Ensuring the safe discharge or transfer of the beneficiary;

(9) Ensuring that the physician receives progress notes when the beneficiary's health condition changes, or when there are deviations from the plan of care;

(10) Ensuring that a summary report of the visit is sent to the physician every sixty (60) calendar days; and

(11) Reporting any instances of abuse, neglect, exploitation or fraud to DHCF and other appropriate District government agencies, including the Department of Health, to promote a safe and therapeutic environment in accordance with 17 DCMR § 5414.

9901.6

For Medicaid reimbursable services, the initial assessment to develop the plan of care and reassessments to update the plan of care shall only be conducted by an R.N. The R.N. conducting an initial assessment or periodic reassessment in accordance with this chapter shall certify in writing that the statements made in the assessment are true and accurate.

9901.7

Consistent with the Department of Health regulations at 22-B DCMR § 3917, Medicaid reimbursable Skilled Nursing services provided by an L.P.N. shall be supervised by an R.N.

9901.8

When an L.P.N. provides Skilled Nursing services, the duties of the L.P.N. shall not include supervisory duties.

9901.9

When an R.N. is supervising a skilled nurse (L.P.N. or R.N.) providing Medicaid reimbursable services, the R.N. shall monitor and supervise the services provided by the L.P.N., R.N., Home Health Aide, or Personal Care Aide, including conducting a site visit at least once every sixty (60) calendar days, or more frequently, if specified in the beneficiary's plan of care.

9901.10

The skilled nurse shall record progress notes during each visit which shall comply with the standards of nursing care established under 17 DCMR §§ 5414 and 5514, and which shall include the following information:

(a) Notations regarding any unusual health or behavioral events or changes in status;

(b) Notations regarding any matter requiring follow-up on the part of the service provider or DHCF; and

(c) A concise written statement of the beneficiary's progress or lack of progress, medical conditions, functional losses, and treatment goals as outlined in the plan of care that demonstrates that the beneficiary's services continue to be reasonable and necessary.

9901.11

The skilled nurse shall prepare summary notes every sixty calendar (60) days summarizing the progress notes recorded at each visit and bringing attention to any matter requiring follow- up on the part of the Home Care Agency or DHCF.

9901.12

Skilled Nursing services shall be reimbursed by Medicaid for up to six (6) hours a day with prior authorization by DHCF, in accordance with the requirements set forth under Subsection 9901.13. Beneficiaries may also qualify for additional reimbursable hours if they meet the requirements referenced under Subsection 9901.16. The need for continuing Skilled Nursing services shall be reassessed and certified by the physician every sixty (60) calendar days.

9901.13

For Medicaid reimbursable services, a beneficiary or his/her physician shall obtain prior authorization for the initiation of Skilled Nursing services by submitting a physician's order as described in Section 9900 to DHCF or its agent to support the beneficiary's need for Skilled Nursing services which aligns with the beneficiary's assessed needs.

9901.14

A Home Care agency shall obtain prior authorization for continuing Medicaid reimbursable Skilled Nursing services every sixty (60) calendar days by submitting an updated physician's order and any supporting documentation to DHCF or its agent to support the beneficiary's need for ongoing Skilled Nursing services which align with the beneficiary's assessed needs, as outlined in the updated plan of care.

9901.15

Medicaid reimbursable Skilled Nursing services may be provided without a prior authorization for up to six (6) hours a day for a period not to exceed five (5) calendar days only when the beneficiary's need for Skilled Nursing services is immediate, such as an emergency situation or to ensure the safe and orderly discharge of the beneficiary from a hospital or nursing home to the beneficiary's home.

9901.16

DHCF may authorize additional hours of Medicaid reimbursable Skilled Nursing services above the six (6) hour per day limit for a beneficiary if DHCF determines that :

(a) Additional hours are medically necessary as reflected on the physician's order described in Subsections 9900.7 through 9900.9;

(b) The beneficiary's needs can be safely met in the home; and

(c) The beneficiary's Medicaid-funded services are being delivered in a cost-effective manner appropriate to the beneficiary's level of care.

9901.17

Beneficiaries enrolled in the § 1915(c) Individuals with Intellectual and Developmental Disabilities (IDD) Home and Community- Based Services Waiver in need of additional hours of Skilled Nursing services beyond those provided under the State Plan may be eligible to receive Skilled Nursing services under the IDD Waiver to the extent the individual has first exhausted the State Plan benefit; qualifies for Skilled Nursing services or extended Skilled Nursing services under 29 DCMR §§ 1931 et seq.; and such services are consistent with the individual's plan of care.

9901.18

The Medicaid reimbursement rate for Skilled Nursing services shall be fifteen dollars ($15.00) for each fifteen (15) minute unit of service for services provided by a R.N., and twelve dollars and fifty cents ($12.50) for each fifteen (15) minute unit of service provided by a L.P.N.

9901.19

The Medicaid reimbursement rate for an initial assessment, reassessment or supervisory visit by a R.N. shall be a flat rate of one hundred and twenty dollars ($120).

9901.20

In order to bill for a fifteen (15) minute unit of Skilled Nursing services, a provider shall ensure that documentation of the visit shows Skilled Nursing services were provided for at least eight (8) minutes during the fifteen (15) minute unit.

9901.21

Medicaid reimbursable Skilled Nursing services shall comply with the following service limitations:

(a) Assessments, reassessments or supervisory visits of a skilled nurse or aide shall not be included in the calculation of the daily Skilled Nursing cap;

(b) When a skilled nurse performs the duties described under Subsections 9901.5(b)-(h) during an initial assessment, reassessment, or supervisory visit, these services shall be included as part of the rate paid for an initial assessment, reassessment, or supervisory visit, and shall not be billed separately; and

(c) When a skilled nurse provides assistance with activities of daily living during an assessment, supervisory, or Skilled Nursing visit, the Home Care agency shall ensure that activities performed during the assessment, supervisory, or Skilled Nursing visit are only billed as Skilled Nursing services and may not also be billed as personal care aide services.

9901.22

Beneficiaries who receive Medicaid-reimbursed Skilled Nursing services may not concurrently receive Medicaid-reimbursed Private Duty Nursing services under the State Plan.

D.C. Mun. Regs. tit. 29, r. 29-9901

Final Rulemaking published at 64 DCR 418 (1/19/2018)