55 Pa. Code 1181 app E
I. Introduction.
(a) The Department has developed criteria to be used in determining whether an applicant or recipient is medically eligible for skilled level of care. To be determined medically eligible for skilled level of care, a recipient must receive at least one skilled care service which meets all of the requirements specified in section II(a). If any one of the requirements specified in section II(a) are not met, the service does not qualify as a skilled care service and recipient cannot be determined to be medically eligible for skilled level of care.
(b) If an applicant is applying for nursing facility care from a nonnursing facility setting and, therefore, does not meet certain conditions, such as receiving a skilled care service on an inpatient basis, the determination should be made based on what services the physician would order and the applicant would receive if the applicant were admitted to a skilled nursing facility.
II. Skilled Care Services.
(a) For an individual service provided to the recipient to be considered a skilled care service, the service shall:
(i) Be required and provided to the recipient on a daily basis.
(ii) Be ordered and provided under the direction of a physician.
(iii) Require the skills of, and be provided either directly by or under the supervision of, medical professionals; for example, registered nurse, licensed practical nurse, physical therapist, occupational therapist, speech pathologist or audiologist.
(iv) Be one that, as a practical matter, can only be provided in a skilled nursing facility on an inpatient basis.
(v) Be documented in the recipient's medical record consistent with standard medical practice.
(b) Skilled care services, as specified in the Skilled Nursing Care Assessment Form Handbook, fall into three categories: skilled nursing services, skilled rehabilitative services and skilled nursing/rehabilitative services.
(i) Skilled nursing services, as specified in the Skilled Nursing Care Assessment Form Handbook include:
(A) Intravenous, intramuscular, or subcutaneous injections and hypodermocylsis or intravenous feedings.
(B) Levin tube and gastrostomy feedings.
(C) Nasopharyngeal and tracheostomy aspiration.
(D) Insertion and sterile irrigation and replacement of catheters.
(E) Application of dressings involving prescription medications and aseptic techniques.
(F) Treatment of extensive decubitus ulcers or other widespread skin disorders.
(G) Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by nurses to adequately evaluate the recipient's progress.
(H) Initial phases of a regimen involving administration of medical gases.
(I) Rehabilitative nursing procedures, including related teaching and adaptive aspects of nursing, that are part of active treatment.
(J) Another skilled nursing procedure that the recipient needs and meets the requirements of section II(a).
(ii) Skilled rehabilitative services, as specified in the Skilled Nursing Care Assessment Form Handbook include:
(A) Therapeutic exercises or activities.
(B) Gait evaluation and training.
(C) Range of motion exercises.
(D) Maintenance therapy: design and establishment of a maintenance program by a qualified therapist based on an initial evaluation and periodic reassessment of the recipient's needs and consistent with the recipient's capacity and tolerance.
(E) Ultrasound, shortwave, and microwave therapy.
(F) Hot pack, hydrocollator, infrared treatments, paraffin baths and whirlpool.
(G) Services of a speech pathologist or audiologist when necessary for the restoration of function in speech or hearing.
(H) Other skilled rehabilitative services that the recipient needs and meets the requirements of section II(a).
(iii) Skilled nursing/rehabilitative services as specified in the Skilled Nursing Care Assessment Form Handbook include:
(A) Overall management and evaluation of care plan-The development, management and evaluation of a patient care plan based on the physician's orders constitute skilled services when, because of the recipient's physical or mental condition, those activities require the involvement of technical or professional personnel to meet the recipient's needs, promote recovery and ensure medical safety. This includes the management of a plan involving a variety of personal care services-nonskilled services-when, in light of the recipient's condition, the aggregate of those services requires the involvement of technical or professional personnel. A condition that does not ordinarily require skilled services may require them because of special medical complications. Under these circumstances, a service that is usually nonskilled may be considered skilled because it must be performed or supervised by skilled nursing or rehabilitative personnel. In situations of this type, the complications, and the skilled services they require, shall be documented by physicians' orders and nursing or therapy notes. Skilled planning and management activities are not always specifically identified in the recipient's clinical record. Therefore, if the recipient's overall condition supports a finding that recovery and safety can be assured only if the total care is planned, managed and evaluated by technical or professional personnel, it is appropriate to infer that skilled services are being provided.
(B) Observation and assessment of the patient's changing condition-Observation and assessment constitute skilled services when the skills of a technical or professional person are required to identify and evaluate the recipient's need for modification of treatment for additional medical procedures until the recipient's condition is stabilized. The need for services of this type shall be documented by physicians' orders and/or nursing or therapy notes.
(C) Patient education services-Patient education services are skilled services if the use of technical or professional personnel is necessary to teach a recipient self-maintenance.
55 Pa. Code 1181 app E
This appendix cited in 55 Pa. Code § 1181.2 (relating to definitions); 55 Pa. Code § 1181.53 (relating to payment conditions related to the recipient's initial need for care) and 55 Pa. Code § 1181.54 (relating to payment conditions related to the recipient's continued need for care).