Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-133.1 - Routine services

Current through Vol. 41, No. 20, July 1, 2024
(a) Nursing
				  facility care includes routine items and services that must be provided
				  directly or through appropriate arrangement by the facility when required by
				  SoonerCare residents. Charges for routine services may not be made to
				  resident's personal funds or to resident family members, guardians , or other
				  parties who have responsibility for the resident. If reimbursement is available
				  from Medicare or another public or private insurance or benefit program, those
				  programs are billed by the facility. In the absence of other available
				  reimbursement, the facility must provide routine services from the funds
				  received from the regular SoonerCare vendor payment and the SoonerCare
				  resident's applied income, or spend down amount.
(b) The OHCA will review the listing
				  periodically for additions or deletions, as indicated. Routine services are
				  member specific and provided in accordance with standard medical care. Routine
				  services include, but are not limited to:
(1)
				  Regular room .
(2) Dietary
				  Services:
(A) regular diets ;
(B) special diets ;
(C) salt and sugar substitutes ;
(D) supplemental feedings ;
(E) special dietary preparations ;
(F) equipment required for preparing and
				  dispensing tube and oral feedings ; and
(G) special feeding devices (furnished or
				  arranged for) .
(3)
				  Medically related social services to attain or maintain the highest practicable
				  physical, mental and psycho-social well-being of each resident, nursing care,
				  and activities programs (costs for a private duty nurse or sitter are not
				  allowed) .
(4) Personal services -
				  personal laundry services for residents (does not include dry cleaning) .
(5) Personal hygiene items
				  (personal care items required to be provided does not include electrical
				  appliances such as shavers and hair dryers, or individual personal batteries) ,
				  to include:
(A) shampoo, comb , and brush;
(B) bath soap;
(C) disinfecting soaps or specialized
				  cleansing agents when indicated to treat or prevent special skin problems or to
				  fight infection;
(D) razor and/or
				  shaving cream;
(E) nail hygiene
				  services; and
(F) sanitary
				  napkins, douche supplies, perineal irrigation equipment, solutions , and
				  disposable douches .
(6) Routine oral hygiene items , including:
(A) toothbrushes ;
(B) toothpaste ;
(C) dental floss ;
(D) lemon glycerin swabs or equivalent
				  products ; and
(E) denture
				  cleaners, denture adhesives, and containers for dental prosthetic appliances
				  such as dentures and partial dentures.
(7) Necessary items furnished routinely as
				  needed to all members , e.g., water pitcher, cup and tray, towels, wash cloths,
				  hospital gowns, emesis basin, bedpan, and urinal.
(8) The facility will furnish as needed items
				  such as alcohol, applicators, cotton balls, tongue depressors and , first aid
				  supplies , including small bandages, ointments and preparations for minor cuts
				  and abrasions, and enema supplies, disposable enemas, gauze, 4 x 4's ABD pads,
				  surgical and micropore tape, telfa gauze, ace bandages, etc.
(9) Over the counter drugs (non-legend) not
				  covered by the prescription drug program (PRN or routine). In general, nursing
				  facilities are not required to provide any particular brand of non-legend
				  drugs, only those items necessary to ensure appropriate care.
(A) If the physician orders a brand specific
				  non-legend drug with no generic equivalent, the facility must provide the drug
				  at no cost to the member . If the physician orders a brand specific non-legend
				  drug that has a generic equivalent, the facility may choose a generic
				  equivalent, upon approval of the ordering physician;
(B) If the physician does not order a
				  specific type or brand of non-legend drug, the facility may choose the type or
				  brand;
(C) If the member, family,
				  or other responsible party (excluding the nursing facility) prefers a specific
				  type or brand of non-legend drug rather than the ones furnished by the
				  facility, the member, family or responsible party may be charged the difference
				  between the cost of the brand the resident requests and the cost of the brand
				  generally provided by the facility. (Facilities are not required to provide an
				  unlimited variety of brands of these items and services. It is the required
				  assessment of resident needs, not resident preferences, that will dictate the
				  variety of products facilities need to provide);
(D) Before purchasing or charging for the
				  preferred items, the facility must secure written authorization from the
				  member, family member, or responsible party indicating his or her desired
				  preference, as well as the date and signature of the person requesting the
				  preferred item. The signature may not be that of an employee of the facility.
				  The authorization is valid until rescinded by the maker of the instrument .
(10) The facility will
				  furnish or obtain any necessary equipment to meet the needs of the member upon
				  physician order. Examples include: trapeze bars and overhead frames, foot and
				  arm boards, bed rails, cradles, wheelchairs and/or geriatric chairs, foot
				  stools, adjustable crutches, canes, walkers, bedside commode chairs, hot water
				  bottles or heating pads , ice bags, sand bags, traction equipment, IV stands,
				  etc.
(11) Physician prescribed
				  lotions, ointments, powders, medications and special dressings for the
				  prevention and treatment of decubitus ulcers, skin tears and related
				  conditions, when medications are not covered under the Vendor Drug Program or
				  other third party payer .
(12)
				  Supplies required for dispensing medications, including needles, syringes
				  including insulin syringes, tubing for IVs, paper cups, medicine containers,
				  etc.
(13) Equipment and supplies
				  required for simple tests and examinations, including scales,
				  sphygmomanometers, stethoscopes, clinitest, acetest, dextrostix, pulse
				  oximeters, blood glucose meters and test strips, etc.
(14) Underpads and diapers, waterproof
				  sheeting and pants, etc., as required for incontinence or other care.
(A) If the assessment and care planning
				  process determines that it is medically necessary for the resident to use
				  diapers as part of a plan to achieve proper management of incontinence, and if
				  the resident has a current physician order for adult diapers, then the facility
				  must provide the diapers without charge;
(B) If the resident or the family requests
				  the use of disposable diapers and they are not prescribed or consistent with
				  the facility's methods for incontinent care, the resident/family would be
				  responsible for the expense .
(15) Oxygen for emergency use, or
				  intermittent use as prescribed by the physician for medical necessity .
(16) Other physician ordered
				  equipment to adequately care for the member and in accordance with standard
				  patient care, including infusion pumps and supplies, and nebulizers and
				  supplies, etc.
(17) Dentures and
				  Related Services. Payment for the cost of dentures and related services is
				  included in the daily rate for routine services. The projected schedule for
				  routine denture services must be documented on the Admission Plan of Care and
				  on the Annual Plan of Care. The medical records must also contain documentation
				  of steps taken to obtain the services . When the provision of denture services
				  is medically appropriate, the nursing facility must make timely arrangements
				  for the provision of these services by licensed dentists. In the event denture
				  services are not medically appropriate, the treatment plan must reflect the
				  reason the services are not considered appropriate, e.g. , the member is unable
				  to ingest solid nutrition or is comatose, etc. When the need for dentures is
				  identified, one set of complete dentures or partial dentures and one dental
				  examination is considered medically appropriate every three years. One rebase
				  and/or one reline is considered appropriate every three years. It is the
				  responsibility of the nursing facility to ensure that the member has adequate
				  assistance in the proper care, maintenance, identification and replacement of
				  these items. The nursing facility cannot set up payment limits which result in
				  barriers to obtaining denture services. However, the nursing facility may
				  restrict the providers of denture services to providers who have entered into
				  payment arrangements with the facility. The facility may also choose to
				  purchase a private insurance dental coverage product for each SoonerCare
				  member. At a minimum, the policy must cover all denture services included in
				  routine services. The member cannot be expected to pay any co-payments and/or
				  deductibles. If a difference of opinion occurs between the nursing facility,
				  member, and/or family regarding the provision of dentures services, the OHCA
				  will be the final authority. All members and/or families must be informed of
				  their right to appeal at the time of admission and yearly thereafter. The
				  member cannot be denied admission to a facility because of the need for denture
				  services.
(18) Vision Services.
				  Routine eye examinations for the purpose of medical screening or prescribing or
				  changing glasses and the cost of glasses are included in the daily rate for
				  routine services. This does not include follow-up or treatment of known eye
				  disease such as diabetic retinopathy, glaucoma, conjunctivitis, corneal ulcers,
				  iritis, etc. Treatment of known eye disease is a benefit of the member's
				  medical plan. The projected schedule for routine vision care must be documented
				  on the Admission Plan of Care and on the Annual Plan of Care. The medical
				  record must contain documentation of the steps that have been taken to access
				  the service. When vision services are not appropriate, documentation of why
				  vision services are not medically appropriate must be included in the treatment
				  plan. For example, the member is comatose, unresponsive, blind, etc. Nursing
				  Home providers may contract with individual eye care providers, providers
				  groups or a vision plan to provide routine vision services to their members.
				  The member cannot be expected to pay any co-payments and/or deductibles.
(A) The following minimum level of services
				  must be included:
(i) Individuals 21 to 40
				  years of age are eligible for one routine eye examination and one pair of
				  glasses every 36 months (three years).
(ii) Individuals 41 to 64 years of age are
				  eligible for one routine eye examination and one pair of glasses every 24
				  months (2 years).
(iii)
				  Individuals 65 years of age or older are eligible for one routine eye
				  examination and one pair of glasses every 12 months (yearly).
(B) It is the responsibility of
				  the nursing facility to ensure that the member has adequate assistance in the
				  proper care, maintenance, identification and replacement of these items. When
				  vision services have been identified as a needed service, nursing facility
				  staff will make timely arrangements for provision of these services by licensed
				  ophthalmologists or optometrists. If a difference of opinion occurs between the
				  nursing facility, member, and/or family regarding the provision of vision
				  services, the OHCA will be the final authority. All members and/or families
				  must be informed of their right to appeal at admission and yearly thereafter.
				  The member cannot be denied admission to the facility because of the need for
				  vision services.
(19)
				  An attendant to accompany SoonerCare eligible members during SoonerRide
				  Non-Emergency Transportation (NET). Please refer to OAC
				  317:30-5-326
				  through OAC
				  317:30-5-327.9
				  for SoonerRide rules regarding members residing in a nursing facility . And
(20) Influenza and pneumococcal
				  vaccinations.