Skilled Nursing Scope of Services

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Skilled Nursing Scope of Services

• Mary Claire Ikenberry, R.N., M.S.
• Department of Education
• Anne Young, R.N.
• Department of Medical Assistance Services
• October 2-3,2007

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Skilled Nursing Scope of Services

• Services are to be
• rendered in accordance to the licensing standards
  and criteria of the Virginia Board of Nursing.
• performed by a Virginia licensed RN or LPN under
  the supervision of an RN.
• The supervision of the LPN is to be consistent
  with the regulatory standards of the Board of
  Nursing.
• Skilled nursing must be part of the I.E.P. or the
  IEP must be amended to include the skilled
  nursing service

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Skilled Nursing Scope of Services

• The service provider must be employed by the
  school division or under contract to the school
  division.
• All skilled nursing services must be directly
  provided and medically necessary.
• Services deemed not medically necessary on
  utilization review audit, will not be covered.

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Skilled Nursing Scope of Services

• SN services will be limited to 6.5 hrs per day or
  26 units per day.
• A unit is 15 minutes of nursing care.
• School year is 180 days.
• Annual maximum number of units for Skilled
  Nursing services is 4680.

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Skilled Nursing Scope of Services

• Services will be consistent with skilled nursing
  services within the scope of their practice.
• These services can include but are not limited
  to
• Dressing changes
• Urinary catheterizations
• Medication Administration

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Plan of Care (Med 10)

• Services will be directly and specifically
  related to an active, written plan of care (POC).
• POC is to be part of the nursing record and is
  the documentation for services.
• The POC is based on a physicians (MD),
  Physicians Assistant (PA) or Nurse
  practitioners (NP) written order for skilled
  nursing services.
• The RN is to establish, sign, and date the POC.

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Plan of Care (Med 10)

• The signing of the POC predates the delivery of
  services.
• The POC is to be periodically renewed or updated
  by a Physician (MD), Nurse Practitioner (NP), or
  Physicians Assistant (PA). Usually this is
  done at the beginning of each school year or at
  anytime the MD/PA/NPs orders are changed.

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Plan of Care (Med 10)

• Services shall be specific and provide effective
  treatment for the childs condition in accordance
  with accepted standards of skilled nursing
  practice.

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Plan of Care (Med 10)

• Skilled nursing services that exceed the MD, PA
  or NPs written order for skilled nursing
  services will NOT be reimbursed by DMAS.

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Plan of Care (Med 10)

• A copy of the Plan of Care shall be given to the
  childs Medicaid Primary Care Physician.

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Documentation of Services

• Will include
• A written POC which identifies
• The medical condition or conditions to be
  addressed by skilled nursing services.
• Goals for skilled nursing services.
• Time tables for accomplishing such stated goals.
• Actual skilled nursing services to be delivered.

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Documentation of Services

• Whether the services will be delivered by an RN
  or LPN.
• Services which have been delivered and for which
  reimbursement from Medicaid is to be claimed,
  must be supported with documentation.

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Documentation of Services

• Will include
• Dates and times of Skilled Nursing services
  entered by the responsible licensed nurse
• Actual nursing services rendered
• ID of the child on each page of the nursing
  record
• Current diagnosis

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Documentation of Services

• The POC will include any prescribed drugs which
  are part of the
• Individualized Educational Program (IEP)
• Including dose, frequency and route
• Treatment
• Following the Specialized Health Care Procedures
  Manual
• Notes to indicate progress made by the student
• Changes from the Physician/NP/PA written order

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Documentation of Services

• Response to treatment
• Actions related to SN services
• Notifying parents
• Calling the physician or
• Notifying the Emergency Medical Services shall
  all be documented
• All documentation shall be signed and dated by
  the person performing the service.

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Documentation of Services

• Skilled nursing services may include extensive
  documentation
• Documentation shall be written
• immediately
• or as soon thereafter as possible
• after the procedure or treatment was implemented
• including the date and time

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Documentation of Services

• If nursing procedures are performed by an LPN,
  they must be supervised by a Registered Nurse in
  accordance with the Board of Nursing Regulations.
  
• If nursing procedures performed by an LPN are to
  be billed to Medicaid then supervision must be
  documented by the RN within a minimum of 30
  calendar days.

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Documentation of Services

• Skilled nursing services documentation will be in
  accordance with the
• Virginia Board of Nursing,
• Department of Health Professions
• Department of Education statues, regulations and
  standards relating to school health
• School Division Medicaid Manual
• Chapter VI (Utilization Review)

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Service Limitations

• Utilization review will be performed by DMAS to
  determine if services are appropriately provided
  to Medicaid recipients and to ensure the services
  are medically necessary and appropriate.
• Failure to document services in the childs
  school nursing record will be considered not
  performed and at utilization review by DMAS,
  payment may be revoked.

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Service Limitations

• When services can be provided by someone other
  than the skilled nursing professional. These
  services may be reimbursable under personal care
  assistant services.

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Skilled Nursing Scope of Services

• Codes have been identified for skilled nursing
  services
• Codes have been identified for nursing services
  are
• T1001 for an assessment
• T1002 for Registered Nursing Services
• T1003 for Services provided by a licensed
  Practical Nurse

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Skilled Nursing Scope of Services

• To calculate these services take the average
  amount of time for the procedure, multiply by the
  number of times a month the service is delivered
  and then divide by 15 (a unit) to get the total
  number of units to be billed.
• Ex. 5 mins to give meds x 18 times a month90
  mins div by 15 mins 6 units.

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Websites DOE- www.doe.virginia.govMedicaid-w
ww.dmas.virginia.govFAMIS-www.famis.org
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Thank You