59G-4.290. Skilled Services

(1) Purpose. This rule establishes the level of care criteria that must be met in order for nursing and rehabilitative services to qualify as skilled services under Medicaid.

(2) Definitions as used in this section.

(a) Continuous. The need for 24-hour care in a skilled nursing facility with professional nursing services available.

(b) Direct supervision. Performance of a procedure in the presence of professional personnel or their presence in the facility during the time in which the procedure is being performed.

(c) Licensed nursing personnel. Registered professional or licensed practical nurses, currently licensed by the State of Florida to practice as a registered nurse or licensed practical nurse respectively.

(d) Professional personnel. Florida licensed or certified physicians, registered nurses, respiratory care practitioners/therapists, audiologists, physical, occupational or speech therapists.

(e) Rehabilitative services. Individualized services prescribed by a health care professional that are designed to restore a recipient to self-sufficiency or to the highest attainable functional level in the shortest possible time following an illness or injury.

(f) Skilled care recipient. A Medicaid applicant or recipient who requires skilled nursing or skilled rehabilitative services.

(3) Skilled Services Criteria.

(a) To be classified as requiring skilled nursing or skilled rehabilitative services in the community or in a nursing facility, the recipient must require the type of medical, nursing or rehabilitative services specified in this subsection.

(b) Skilled Nursing. To be classified as skilled nursing service, the service must meet all of the following conditions:

1. Ordered by and remain under the supervision of a physician;

2. Sufficiently medically complex to require supervision, assessment, planning, or intervention by a registered nurse.

3. Required to be performed by, or under the direct supervision of, a registered nurse or other health care professionals for safe and effective performance;

4. Required on a daily basis;

5. Reasonable and necessary to the treatment of a specific documented illness or injury; and

6. Consistent with the nature and severity of the individual’s condition or the disease state or stage.

(c) Examples of services that qualify as skilled nursing services:

1. Intravenous medication or fluids.

2. Intramuscular or subcutaneous injection and hypodermoclysis when:

a. Administered by licensed nursing personnel at least 5 times weekly, excluding daily insulin administration, and

b. Observation is necessary to assess the recipient’s response to treatment or to identify adverse reactions.

3. Management and monitoring medication regime on a daily basis:

a. For drugs whose dosage requirements may rapidly change;

b. For drugs prone to cause adverse reactions, severe side effects or unfavorable reactions; and

c. For residents with unstable conditions.

4. Levin tube and gastrostomy feedings; excluding feedings performed by residents, family members, or friends.

5. Administration of medical gases, aerosolized medication or oxygen which is started, monitored and regulated by professional staff.

6. Naso-pharyngeal and tracheotomy aspiration, excluding tracheotomy care in self-care residents.

7. Insertion, replacement, and sterile irrigation of catheters when:

a. Medically necessary or required for reasons other than to maintain satisfactory catheter functioning and dryness;

b. The medical need is documented by the physician;

c. Continuous irrigation, frequent insertion, special care or observation is required because of bleeding, infection, obstruction, or heavy sediment formations; and

d. Care of a recently inserted supra-pubic catheter, inserted within 2-4 weeks, is required.

8. Colostomy and ileostomy care:

a. When medically necessary and required during early postoperative period;

b. During the period of initial self-care training; or

c. When complications are present and documented in the medical record.

9. Treatment of decubitus ulcers when:

a. Deep or wide without necrotic center;

b. Deep or wide with layers of necrotic tissue; or

c. Infected and draining.

10. Treatment of widespread infected or draining skin disorders.

11. Application of dressings involving prescription medication and aseptic techniques when documented as required on a daily basis. Excludes simple dressings involving non-infected cases, simple skin breaks, and healed postoperative incisions.

12. Heat treatments prescribed by a physician as daily treatment for a specific condition.

13. Rehabilitation nursing procedures required on a daily basis as necessary to restore functioning, including teaching and adaptive aspects of nursing.

(4) Skilled Rehabilitative Services. To be classified as skilled rehabilitative services, the services must meet all of the following conditions:

(a) Ordered by and remain under the supervision of a physician;

(b) Reasonable and necessary to the treatment of a recent or presently existing illness or injury;

(c) Performed by a physical therapist, occupational therapist, certified respiratory care practitioner/therapist;

(d) Required at least 5 days a week; and

(e) Reviewed and reevaluated at least every 30 days by the physician and the physical, occupational therapist or respiratory care practitioner/therapist.

(5) Examples of services that qualify as skilled rehabilitation services:

(a) Daily services of a speech pathologist or audiologist when necessary for the restoration of function in speech or hearing.

(b) Ongoing assessment of rehabilitation potential and needs in accordance with Rule 59G-4.320, F.A.C.

1. Such services must be provided as an integral part of the management of the care plan; and

2. Must include results of tests and measurements of range of motion, strength, balance, coordination, endurance, functional ability, physical capacities, perceptual deficits, speech and language or hearing disorders.

(c) Therapeutic exercise or activities that, because of the type of exercise employed or the condition of the recipient, must be performed by or under the supervision of a qualified physical therapist or occupational therapist to ensure the safety of the recipient and the effectiveness of the treatment.

(d) Gait evaluation and training when furnished in accordance with the treatment plan and designed to restore function to a recipient whose ability to walk has been impaired by neurological, muscular or skeletal abnormalities.

(e) Range of motion exercises that are part of the active treatment for a specific disease state which has resulted in a loss of, or restriction of, mobility as evidenced by a therapist’s notes showing the degree of motion lost and the degree to be restored.

(f) Maintenance therapy, when the specialized knowledge, skills, and judgment of a qualified therapist are required to design and implement a maintenance program based on an initial evaluation and periodic assessment of the recipient’s needs, and consistent with the recipient’s capacity and tolerance. For example, a recipient with Parkinson’s disease who has not been under a rehabilitative program may require the services of a qualified therapist to determine the type of exercise that will contribute the most to the maintenance of his present level of functioning.

(g) Ultrasound, short-wave and microwave therapy by a qualified physical therapist.

(h) Hot pack, hydrocollator, infrared treatments, paraffin baths, and whirlpool in cases in which the recipient’s condition is complicated by circulatory deficiency, areas of desensitization, or complications, and the skills, knowledge and judgment of a qualified physical therapist are required.

(i) Chest physiotherapy or augmentary airway clearance techniques, maintain airway patency and lung volume.

(6) Examples of services that qualify as either skilled nursing or skilled rehabilitative services:

(a) Ongoing involvement of registered nurses or other professional personnel in the evaluation of the total needs of a resident and management of the treatment plan.

(b) Continuous observation and monitoring for complications, adverse reactions, or changes in the status of a recipient’s condition when required to identify and evaluate the individual’s need for modification of the treatment plan or institution of a critical medical procedure.

(c) Ongoing teaching and training activities that are required to teach a recipient or caregiver how to manage the treatment regime or perform self care or treatment skills. This service must be ordered by the physician and evidenced by a recent change in the health status of the resident. Skilled teaching and training services must be documented on at least a daily basis in the progress notes.

(7) Medically fragile. To be classified as medically fragile, the applicant or recipient must be:

(a) Age birth through age 20 years old;

(b) Require skilled nursing in a nursing facility; and

(c) Be technologically dependent on apparatus or procedures to sustain life, or require significantly more intense and continual professional nursing supervision and intervention to sustain life and who, without the provision of such continuous services and observation, is likely to expire.

(8) Services shall be considered skilled in cases in which medically complex condition(s) or medically fragile condition(s) are documented by a physician, or when the instability of the recipient’s condition requires frequent nursing intervention, observation and assessment of the recipient’s status and response to care.

(9) The restorative or recovery potential of the individual shall not be a factor when determining the need for skilled services.

(10) To qualify for placement in a nursing facility, the applicant or recipient must require 24 hour observation and care and the constant availability of medical and nursing treatment and care, but not to the degree of care and services provided in a hospital.

(11) When determining whether nursing facility services are required, consideration shall be given to the individual’s physical and mental condition, excluding individuals with functional psychoses, acute psychiatric illness or individuals requiring or receiving active psychiatric treatment, or who require 24-hour care for diagnostic evaluation and psychiatric treatment.

Rulemaking Authority 409.919 FS. Law Implemented 409.905(2), (5), (8), 409.906(11) FS. History–New 1-1-77, Amended 8-29-77, Formerly 10C-7.32, Amended 6-22-86, Formerly 10C-7.032, Amended 2-21-95.