Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › APPEALS OF ADVERSE DETERMINATIONS › Appendix E - SKILLED NURSING CARE

Current through Register Vol. 54, No. 28, July 13, 2024
I.
Introduction.
(a) The Department has developed criteria to be used in
						determining whether an applicant or recipient is medically eligible for skilled
						level of care. To be determined medically eligible for skilled level of care, a
						recipient must receive at least one skilled care service which meets all of the
						requirements specified in section II(a). If any one of the requirements
						specified in section II(a) are not met, the service does not qualify as a
						skilled care service and recipient cannot be determined to be medically
						eligible for skilled level of care.
(b) If an applicant is applying for nursing facility care
						from a nonnursing facility setting and, therefore, does not meet certain
						conditions, such as receiving a skilled care service on an inpatient basis, the
						determination should be made based on what services the physician would order
						and the applicant would receive if the applicant were admitted to a skilled
						nursing facility.
II.
Skilled Care Services.
(a) For an individual service provided to the recipient
						to be considered a skilled care service, the service shall:
(i) Be required and provided to the recipient on a daily
						basis.
(ii) Be ordered and provided under the direction of a
						physician.
(iii) Require the skills of, and be provided either
						directly by or under the supervision of, medical professionals; for example,
						registered nurse, licensed practical nurse, physical therapist, occupational
						therapist, speech pathologist or audiologist.
(iv) Be one that, as a practical matter, can only be
						provided in a skilled nursing facility on an inpatient basis.
(v) Be documented in the recipient's medical record
						consistent with standard medical practice.
(b) Skilled care services, as specified in the
Skilled Nursing Care Assessment Form Handbook,
fall into three
						categories: skilled nursing services, skilled rehabilitative services and
						skilled nursing/rehabilitative services.
(i) Skilled nursing services, as specified in the
Skilled Nursing Care Assessment Form Handbook
include:
(A) Intravenous, intramuscular, or subcutaneous
						injections and hypodermocylsis or intravenous feedings.
(B) Levin tube and gastrostomy feedings.
(C) Nasopharyngeal and tracheostomy aspiration.
(D) Insertion and sterile irrigation and replacement of
						catheters.
(E) Application of dressings involving prescription
						medications and aseptic techniques.
(F) Treatment of extensive decubitus ulcers or other
						widespread skin disorders.
(G) Heat treatments which have been specifically ordered
						by a physician as part of active treatment and which require observation by
						nurses to adequately evaluate the recipient's progress.
(H) Initial phases of a regimen involving administration
						of medical gases.
(I) Rehabilitative nursing procedures, including related
						teaching and adaptive aspects of nursing, that are part of active
						treatment.
(J) Another skilled nursing procedure that the recipient
						needs and meets the requirements of section II(a).
(ii) Skilled rehabilitative services, as specified in the
Skilled Nursing Care Assessment Form Handbook
include:
(A) Therapeutic exercises or activities.
(B) Gait evaluation and training.
(C) Range of motion exercises.
(D) Maintenance therapy: design and establishment of a
						maintenance program by a qualified therapist based on an initial evaluation and
						periodic reassessment of the recipient's needs and consistent with the
						recipient's capacity and tolerance.
(E) Ultrasound, shortwave, and microwave therapy.
(F) Hot pack, hydrocollator, infrared treatments,
						paraffin baths and whirlpool.
(G) Services of a speech pathologist or audiologist when
						necessary for the restoration of function in speech or hearing.
(H) Other skilled rehabilitative services that the
						recipient needs and meets the requirements of section II(a).
(iii) Skilled nursing/rehabilitative services as
						specified in the
Skilled Nursing Care Assessment Form Handbook
include:
(A)
Overall management and evaluation of care
						plan
-The development, management and evaluation of a patient care plan
						based on the physician's orders constitute skilled services when, because of
						the recipient's physical or mental condition, those activities require the
						involvement of technical or professional personnel to meet the recipient's
						needs, promote recovery and ensure medical safety. This includes the management
						of a plan involving a variety of personal care services-nonskilled
						services-when, in light of the recipient's condition, the aggregate of those
						services requires the involvement of technical or professional personnel. A
						condition that does not ordinarily require skilled services may require them
						because of special medical complications. Under these circumstances, a service
						that is usually nonskilled may be considered skilled because it must be
						performed or supervised by skilled nursing or rehabilitative personnel. In
						situations of this type, the complications, and the skilled services they
						require, shall be documented by physicians' orders and nursing or therapy
						notes. Skilled planning and management activities are not always specifically
						identified in the recipient's clinical record. Therefore, if the recipient's
						overall condition supports a finding that recovery and safety can be assured
						only if the total care is planned, managed and evaluated by technical or
						professional personnel, it is appropriate to infer that skilled services are
						being provided.
(B)
Observation and assessment of the patient's
						changing condition
-Observation and assessment constitute skilled
						services when the skills of a technical or professional person are required to
						identify and evaluate the recipient's need for modification of treatment for
						additional medical procedures until the recipient's condition is stabilized.
						The need for services of this type shall be documented by physicians' orders
						and/or nursing or therapy notes.
(C)
Patient education services
-Patient
						education services are skilled services if the use of technical or professional
						personnel is necessary to teach a recipient self-maintenance.
This appendix cited in 55 Pa. Code §
													1181.2 (relating to definitions);
						  55 Pa. Code §
													1181.53 (relating to payment
						  conditions related to the recipient's initial need for care) and 55 Pa. Code
						  §
													1181.54 (relating to payment
						  conditions related to the recipient's continued need for
						  care).