S.D. Admin. R. 67:16:43:04

Current through Register Vol. 51, page 57, November 12, 2024

Section 67:16:43:04 - Admission requirements

Admission to a medically complex program is a covered service if the following criteria are met:

(1) Medical documentation substantiates that the service is medically necessary. Medical documentation includes a diagnosis, a complete medical history, copies of progress notes from physicians or other professionals providing care or services, laboratory tests, X rays, physician or other licensed practitioner orders and a treatment plan outlining the needed care, and any other documentation which may be necessary to determine medical necessity for the child's admission;

(2) Home health care is not a viable option as determined by the department based on the child's medical needs, the availability of home health services, and cost effectiveness;

(3) The facility has notified the child's school district that the child has been referred to the facility for services and may be in need of an educational program;

(4) The cost of care does not exceed the cost of care in the child's home; and

(5) Professional nursing services are necessary on a 24-hour basis and the child requires at least two of the following services:

(a) Intravenous medications more than twice a day which must be administered by a registered nurse;

(b) Drug therapy stabilization which requires skilled monitoring on a 24-hour basis;

(c) Nutritional therapy during an unstable period;

(d) Alternative nutritional feeding, such as nasogastric or gastrostomy feeding, during an unstable period;

(e) Tracheostomy care during an unstable period;

(f) Colostomy or ileostomy care during an unstable period;

(g) Skilled skin care and monitoring for the treatment of a decubitus ulcer;

(h) Monitoring of oxygen saturation when oxygen is being administered;

(i) Skilled nursing observation and assessment following casting or surgeries;

(j) Direct paraprofessional care for more than eight hours a day which is supervised by a medical professional;

(k) Peritoneal dialysis during an unstable period;

(l) Infectious disease care during an unstable period;

(m) Use of a ventilator during an unstable period; or

(n) Professional monitoring to manage end stage disease process.

For purposes of this rule, an unstable period is that period of time necessary for a child to return to a medically stable state following a disease process, illness, or surgery.

S.D. Admin. R. 67:16:43:04

23 SDR 2, effective 7/15/1996; 44 SDR 94, effective 12/4/2017

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1(1)(2)(4).

Covered services must be medically necessary, § 67:16:01:06.02.