411-048-0180 Long Term Care Community Nursing Services When authorized by an individual's case manager, the following long term care community nursing services must be provided by an RN in accordance with these rules and the scope of practice as stated in the OSBN rules in OAR chapter 851. (1) REVIEW OF REFERRAL. An RN must screen a referral and notify the individual's case manager of their decision to accept or refuse the referral within two business days of receiving the referral on the Department approved form. The RN may refuse any referral. (2) INITIAL ASSESSMENT. The RN must perform a face-to-face nursing assessment within 10 business days following the acceptance of a referral. The assessment is defined in OAR chapter 851, division 006 and regulated by OAR chapter 851, division 045. (a) The RN must document the nursing assessment pursuant to OAR chapter 851, divisions 006 and 045. (b) The RN must send copies of the nursing assessment to the individual's case manager. If the RN recommends ongoing long term care community nursing services, the RN must also send a copy of the Nursing Service Plan as described in section (4) of this rule.. (3) REASSESSMENT. For the purpose of this rule, the RN must perform a face-to-face reassessment and update the individual's Nursing Service Plan at a minimum annually. Based on the RN’s assessment of the individual, the RN may determine that an assessment needs to occur more frequently. Reasons for increased frequency may include, but are not limited to, a change of condition or change of environment. (a) The RN must complete the reassessment within 10 business days of the date the reassessment started. (b) The RN must document the date, time and results of the reassessment and send copies of the reassessment to the individual's case manager and include an updated Nursing Service Plan as described in section (4) of this rule. (c) Each reassessment requires the RN to update the nursing service plan and perform a medication review. The documentation must support the reason for the re-assessment, have a detailed description of the activities the RN provided to develop the new nursing service plan and include detailed information about the changes in the individual’s condition and the scope, duration, and frequency of all nursing interventions. (4) NURSING SERVICE PLAN. Based on the initial assessment or reassessment, the RN develops or updates the individual's Nursing Service Plan and must: (a) Prioritize actual or potential client needs, risk of both; (b) Identify expected outcomes for needs and risks identified using quantitative and qualitative measures of effectiveness; (c) Establish interventions and strategies designed to assist the client in attaining expected outcomes and the planned scope, duration and frequency of each intervention; (d) Identify implementation, timelines, and documentation requirements for the plan of care; (e) Utilize standardized language appropriate to the context of care; (f) Complete and document Nursing Service Plan on the Department approved form and provide the Nursing Service Plan to an Individual’s case manager within 10 business days of the date that an initial assessment or a reassessment is initiated; and (g) Attend a minimum of two Nursing Service Plan review meetings each year with an individual’s case manager. This meeting can be held face-to-face, phone or other secure state approved conference technology. (5) DELEGATION. The RN must follow the standards and documentation requirements for delegation of nursing tasks as required by OAR chapter 851, divisions 006, 045, and 047. (a) The RN alone, based on professional judgment and the Oregon Nurse Practice Act regulations, makes the determination to delegate or not delegate a nursing procedure to a UAP, or to rescind a UAP’s authorization to perform a nursing procedure. (b) The RN must provide the case manager with: (A) An estimate of the number of hours required for the delegation process; (B) The individual delegation process needs identified in the Nursing Service Plan; and (C) Keep the case manager informed of ongoing delegation activities on the Nursing Service Summary form (SDS 0752) and Nursing Service Plan form (SDS 0754). (c) The RN must keep Medicaid funded home and community-based setting providers informed through completion of the Nursing Service Summary form (SDS 0754) for delegation at initial assessment and all subsequent delegation activities of the delegation decisions and activities provided to unregulated assistive person.. (6) TEACHING. The RN must follow the standards and documentation requirements for teaching health promotion as described in OAR 851-045-0060. (a) The RN must develop and document a teaching plan that describes and communicates the reason the teaching is needed and the specific goals for the individual or the individual's caregiver. (b) Teaching related to non-injectable medications must be provided by an RN in accordance with OAR chapter 851, division 045 and The Teaching of the Administration of Lifesaving Treatments specific to intramuscular injections identified in ORS 433.800 through 433.830 must be provided by the RN in accordance with Oregon Health Authority Training on Lifesaving Treatment Protocols. https://www.oregon.gov/oha/ph/providerpartnerresources/emstraumasystems/pages/epi-protocol-training.aspx (7) MONITORING. The RN must provide monitoring visits at the individual’s home, sufficient in frequency and duration to implement and keep current an individual's Nursing Service Plan. (a) The RN must document the projected frequency of monitoring visits in an individual's Nursing Service Plan and may adjust the frequency based on the complexity of the Nursing Service Plan and the individual's needs. (b) Calls with providers, caregivers, or an individual to review health status, follow up on instructions, or exchange information related to care coordination are considered a monitoring visit. (8) MEDICATION REVIEW. The RN must provide a medication review during each monitoring visit and as part of an initial assessment or reassessment. The scope of a medication review shall be based on the needs of the individual or the individual's caregiver. Information collected and evaluated as part of a medication review may result in changes to an RN's nursing plan of care, subsequent Teaching Plan or care coordination activity. (9) CARE COORDINATION. The RN provides care coordination in order to advocate for health care services that an individual needs and to gather the information that is needed to complete the assessment, nursing service plan or reassessment process, and medication review. The RN uses care coordination to provide updated information to people involved in an individual’s health care via phone calls, faxes, electronic mediums, or meetings. Care coordination is provided, but not limited, to case managers, other nurses, healthcare providers, and non-caregiving family members or legal representatives. (10) Time spent completing the services described in sections (3) through (9) of this rule may be included in the claim for the respective service but must meet documentation standards specified in OAR 410-120-1360(2)(a)(b) and the Department’s Long Term Care Community Nursing Procedure Codes and Payment Authorization Guidelines. (11) PRIOR AUTHORIZATION. All long term care community nursing services in sections (2) through (9) of this rule must be prior authorized by an individual’s case manager. (a) The RN must use an individual's Nursing Service Plan to estimate the number of hours needed for long term care community nursing services within a six month time period. The RN must document the estimated number of long term care community nursing service hours on the Department approved form for authorization and send the Department approved form for authorization to the individual's case manager. (b) The case manager must authorize the proposed hours after reviewing the individual's completed Nursing Service Plan. The case manager must complete the prior authorization within five business days of receiving the Department approved form for authorization and the individual's completed Nursing Service Plan. (12) Prior authorization for the initial assessment and delegation of services described in sections (2) and (5) of this rule is granted once the Department approved form for referral is signed by the RN and the individual's case manager. The payment received by an RN for initial assessment shall include compensation for all long term care community nursing services excluding delegation, provided by the RN to the individual and the individual's caregiver. Payment is not provided until prior authorization as described in section (11) of this rule has been provided to the RN by the individual's case manager. (13) The RN must use the Department approved Service Summary form as the communication tool for case managers and caregivers to document the monitoring, care coordination, teaching, delegation, or other services as noted in these rules provided to each individual. (14) A local office manager may grant an exception to the timeframes required in this rule on a case specific basis. Statutory/Other Authority: ORS 409.050 & 410.070 Statutes/Other Implemented: ORS 409.010 & 410.070 History: APD 18-2023, amend filed 10/13/2023, effective 11/01/2023 APD 30-2021, amend filed 08/25/2021, effective 08/25/2021 SPD 8-2013, f. & cert. ef. 4-15-13