Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 3 - Criteria for Level of Care in Long Term Care Facilities › Section 3-3 - Examples illustrating criteria for level of care; differentiation between skilled and intermediate care

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 3.
The following examples illustrate some of the considerations
				  involved in the differentiation between Skilled and Intermediate care.
SKILLED CARE
INTERMEDIATE CARE
Anemia
Rapid breakdown of red blood cells which may
								produce a hemolytic crisis. Treatment - intravenous solutions or
Frequently present in the elderly. Oral medication
								or infrequent injections usually sufficient for routine treatment.
Arteriosclerosic Heart Disease
Severe vascular heart disease requiring powerful
								antihypertensive drugs. There may be symptoms of heart failure requiring
								accurate digitalization and diuretics.
Minimal or moderate amounts of medication without
								adjustment to medications.
Arthritis
Drugs used in large doses and over a prolonged
								period of time that may produce metabolic or toxic symptoms.
Long history of chronic arthritis. Routine
								medication and physical therapy.
Brain Syndromes (Psychoses)
Must receive active treatment. (1) Treatment
								developed by a physician in conjunction with staff members. (2) Services are
								expected to improve the patient's condition and level of functioning. (3)
								Services are supervised and evaluated by a physician and documented in the
								medical record.
Therapy not planned for the particular patient.
								Activities are diversional in nature, i.e., to provide social or recreational
								outlet for the patient. Non-energetic treatment with medications.
Bronchitis (chronic) and
								Bronchiectasis
Limited pulmonary reserve with changes in oxygen
								requirements. Intractable congestive heart failure.
Standard oral medication. Patient has been taught
								to manage own inhalation equipment.
Cataract
Skilled care required for 14 days because of very
								recent surgery or complications.
Usually cataract extractions are followed by a
								normal uncomplicated convalescence in the hospital and discharge to the
								patient's home.
Cancer
Recent major surgery. Current treatment with
								radium, radioactive isotopes, X-ray, and anti-neoplastic agents. Active
								treatment for serious complications such as severe pain, acute infections,
								decubiti, fractures, special training while patient learns to handle appliances
								or surgical wounds, including colostomy.
No specific treatment. Considered arrested. If
								metastasis, the cancer is not being actively treated.
Cerebrovascular Accident
Hemiplegia and/or speech disturbance. Less than six
								months since cerebrovascular accident. Active speech or physical
								therapy.
Small cerebral vessel involved with minor paralysis
								(Ischemia Attacks). Patient can ambulate. More than six months since
								C.V.A.
Cirrhosis of Liver
Persistent ascites being treated by diuretics, by
								paracentesis or both.
Bed rest and diet. Moderate use of diuretic
								drugs.
Congestive Heart Failure
Patient requires vigorous and comprehensive
								treatment. Severe shortness of breath, requiring tourniquets on limbs,
								phlebotomy, or oxygen therapy.
Incipient or mild failure with exertional shortness
								of breath, fatigue, and perhaps edema of the ankles, which usually subside
								readily with diuretic and digitalis therapy.
Convulsions
Frequent attacks due to serious brain diseases,
								such as tumors, cerebral edema, and cerebrovascular accidents. Difficult to
								control.
Infrequent attacks that can be controlled or
								alleviated by medication. Frequency of once a month will be considered skilled
								care.
Decubitus Ulcer
Energetic treatment by debridement of necrotic
								tissue, medications, and bandages. Tissue necrosis and infection must be
								actively treated.
Minor healing decubiti or skin care to prevent
								decubiti.
Diabetes Mellitus
Severe or "brittle" diabetes. Variations in insulin
								requirements. Also for the juvenile diabetic.
Diabetes easily controlled by diet and oral
								medication or insulin.
Emotional Disturbances
To control severe agitation or depression for short
								period of time, large doses of tranquilizers or anti-depressives are required.
								Close supervision is required (when IM medications are being given
								daily).
Anxiety and depression are not severe. Mental
								condition does not require close continuous supervision.
Emphysema
"Respiratory cripple" may show symptoms of
								respiratory infection, severe bronchial secretion, carbon dioxide retention,
								and cardiac failure. These symptoms require energetic medical
								treatment.
Symptoms of wheezing, chronic cough, and mild
								dyspnea which do not require special treatment by skilled personnel. Patient
								may require IPPB treatment for a period.
Fractures
Many factors are involved in the amount of skilled
								care patient requires. Care depends upon the location of the fracture, the
								degree of healing, the type of treatment, and the severity of any
								complications.
The healing process is almost complete. Restorative
								physical therapy may be necessary.
Hypertensive Heart
								Disease
Vigorous and diligent treatment for patient showing
								cerebral signs (encephalopathy) strokes, transient hemiparesis, cardiac
								insufficiency, coronary ischemia, and severe headaches not controlled by
								routine analgesics.
Patient has been on long-term antihypertensive
								therapy or alarming symptoms are absent and the patient is not under vigorous
								treatment.
Malnutrition
Condition is so serious that patient requires
								frequent visits by his physician. I.V. or tube feedings generally
								required.
Patient's poor eating habits are corrected by
								special diets.
Myocardial Infarction
Recent infarction. Relative rest for the injured
								heart. Possible congestive heart failure.
Attack over 2 - 3 months ago. Routine prophylaxis
								(anticoagulants) against thromboembolic complications. Heart
								compensating.
Nephritis, Nephrosclerosis,
								Nephroses
Acute phase of these conditions requires active
								therapy. In the chronic state they may require special treatment for heart
								failure, electrolyte abnormalities, acidosis and uremia.
Many elderly patients suffer from renal diseases.
								Treatment often is a dietary regimen and diuretic drugs.
Osteoporosis
Collapse and wedging of the atrophic vertebral
								bones may appear under minimal stress. Skilled care will be required to treat
								the fracture or alleviate the pain.
This condition is found in many elderly people.
								Oral medications may be administered.
Transferred from the Division of Family and Children
					 (470 IAC 5-3-4) to the Office of
					 the Secretary of Family and Social Services (405 IAC
					 1-3-3) by
					 P.L.
					 9-1991,
					 SECTION
					 131, effective January 1,
					 1992.