OKLAHOMA HEALTH CARE AUTHORITY HOME AND COMMUNITY-BASED WAIVER SERVICES FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES ADDENDUM I

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1 OKLAHOMA HEALTH CARE AUTHORITY HOME AND COMMUNITY-BASED WAIVER SERVICES FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES ADDENDUM I PROVIDER TITLE: Home Health Care/Skilled Nursing Services MINIMUM QUALIFICATIONS: Individual providers must be currently licensed in the State of Oklahoma or in the state that services are provided as either a Registered Nurse to provide Registered Nursing Services or Licensed Nursing Services or licensed as a Licensed Practical Nurse to provide Licensed Nursing Services. Agency providers must have a current Medicaid Home Health Agency (provider type 09) contract or have received certification from the Department of Health as a Home Health Care Agency. DESCRIPTION OF SERVICES: Skilled Nursing Service providers will provide all services in community-based settings where the member/service recipient resides. Nursing services funded through DDSD are as follows: Extended Duty Skilled Nursing Care. Extended Duty Skilled Nursing Care allows a licensed nurse to provide direct services in a community setting up to 24 hours per day. 1. Extended Duty Nursing Care must be: a. provided only to those member/service recipients who have health-related issues that are unstable, requiring skilled treatment or other intervention by a licensed nurse more frequently than every two hours; b. ordered by a physician; c. provided in accordance with the requirements of OAC 340: ; and d. documented in the member/service recipient s DDSD Plan of Care. 2. Extended Duty Nursing Care includes: a. skilled nursing care and interventions rendered directly to the member/service recipient by the nurse; b. monitoring, evaluation, and documentation of the member/service recipient's physical or mental status; c. administration of medication or treatments or both as ordered by the physician; d. documentation of medication or treatment administration, skilled nursing interventions, member/service recipient's responses to medication or treatment, and any adverse reactions, or other significant changes; e. implementation of all tasks and objectives of the written nursing plan of care; and f. performance of training and general care to the member/service recipient during periods in that skilled nursing tasks and interventions are not being performed. 1

2 Intermittent Skilled Nursing Care. Intermittent Skilled Nursing Care involves performance of intermittent skilled tasks or interventions that only a licensed nurse can perform (OAC 340: ). Examples of intermittent tasks include sterile wound care, sterile catheterization, administration of injections or IV medications, and other skilled services that cannot be delegated to non-licensed paid staff. This service is limited to no more than three intermittent skilled tasks or interventions for any individual DDSD member/service recipient in a 24-hour period. Exceptions to this service limitation can only be granted upon review and written approval of the DDSD State Nursing Director or designee. 1. Intermittent Skilled Nursing Care must be: a. ordered by a physician; b. provided in accordance with the requirements of the DDSD Health Services Policy (OAC 340: ); and c. documented in the member/service recipient s DDSD Plan of Care. 2. Intermittent Skilled Nursing Care includes: a. skilled nursing care and interventions rendered directly to the member/service recipient, as ordered by the physician; examples include sterile wound care, sterile catheterization, administration of injections or IV medications, and other skilled services that cannot be delegated to nonlicensed paid staff. b. health-related assessments; c. administration of medication or treatments ordered by the physician; d. documentation of medication or treatment administration, and skilled nursing care or interventions, the member/service recipient's response to medication, treatment, or the skilled nursing care or intervention and any adverse reaction or other significant changes; and e. implementation of all tasks and objectives of the written nursing plan of care. Individualized Skilled Nurse Training and Evaluation. Individualized Skilled Nurse Training and Evaluation provides DDSD member/service recipients with individualized evaluation and oversight of health care needs by a licensed nurse and specific, individualized health training by a licensed nurse to the member/service recipient or the member/service recipient's family or paid caregivers. This service would be reimbursed on a 15-minute unit of service basis, with a maximum limit of 16 units/month. Exceptions to this service limitation can only be granted upon review and written approval of the DDSD State Nursing Director or designee. The licensed nurse assesses the member/service recipient's training needs prior to initiating competency-based training and develops a nursing plan of care that outlines the methods, goals, and objectives of the training to be performed. The nurse exercises prudent judgment in making the final decision as to what may be trained and delegated to community service workers, as provided by Section 1020 of Title 56 of the Oklahoma Statutes. 2

3 Services include: 1. individualized nurse training or evaluation or both provided directly to the member/service recipient, family, or paid caregiver(s), as identified in the individual plan and the nursing plan of care; 2. evaluation and documentation of the competency of individuals trained through return demonstration, written test, verbalization of understanding, or other means suitable to the type of training performed; 3. professional monitoring and supervision to the community service worker in accordance with the applicable licensing requirements and evaluation of: a. the stability of the condition of the member/service recipient; b. the training and capability of the person receiving training; c. the nature of the task being trained; and d. the proximity and availability of the licensed nurse to the person when the task is being performed; and e. attendance at required meetings as specified in the individual plan. All nursing services must meet and support DDSD criteria to Establish Service Necessity (OAC 340: ) A monthly summary of the progress on assigned outcomes and action steps, as specified in the member/service recipient s DDSD Plan of Care, will be submitted to the member/service recipient s DDSD case manager in accordance with OAC 340: Payment rates and service limitations for Nursing Services will be as promulgated in the Oklahoma Health Care Authority Administrative Code. Service Requirements A. Services 1. The Provider must deliver services in a manner that contributes to the member/service recipient's enhanced independence, self-sufficiency, community inclusion and well-being. 2. The provider serves as a member of the personal support team as described in OAC 340: through , and submits required paperwork as specified by these policies. 3. The Provider must make reasonable effort to ensure persons served through this Contract are afforded freedom of choice in all aspects of service provision, for which the Provider is responsible, unless such choice jeopardizes the member/service recipient's independence and well-being. 4. The Provider must not provide services that duplicate the services mandated to be provided by the public school district pursuant to the Individuals With Disabilities Education Act. 3

4 5. The Provider must be responsible for supplying training in accordance with OAC 317: , in individual specific health care practices to the member/service recipient, the member/service recipient s family or paid caregivers, regardless of whether or not they are employed by the Provider, member/service recipient or member/service recipient's family. 6. The Provider must perform training and general care to the member/service recipient during periods in that skilled nursing tasks and interventions are not being performed. 7. The provider must ensure that all services are rendered in accordance with the Oklahoma Nursing Practice Act, the Oklahoma Health Care Authority, the Oklahoma Department of Health and the Oklahoma Department of Human Services. 8. The Provider may only claim reimbursement for services authorized and provided. 9. Claims must be made for the date service is actually provided. Periods of time less than 15 minutes on separate dates are not compensable. Routine recording of office paperwork, billing information and claims documentation is not compensable. However, time spent in preparing DDSD required reports is compensable. B. Staffing 1. The Provider must ensure that a Registered Nurse provides clinical supervision of any assigned licensed practical nurses, and oversight guidance for Licensed Practical Nurses and direct service staff as assigned are provided in accordance with the Oklahoma Nurse Practice Act and Home Care Act. Any Registered Nursing level of care must be provided by a Registered Nurse, and the service must be provided on site. 2. The Provider must conduct a pre-employment screening of the employment history of any person who is employed or utilized as a volunteer in the provision of services to reduce the potential for abuse, neglect or exploitation of member/service recipients. The Provider must indemnify and hold the Department harmless for any damages or attorney fees resulting from a claim that an employee abused, neglected or otherwise injured a person. 3. The Provider must designate one individual who must be responsible for the administration of the agency/services provided and is empowered to act on behalf of the Provider. 4. The Provider must ensure that employees are specifically trained to meet the unique needs of each member/service recipient. 4

5 5. The service to be performed under this Contract must not be subcontracted, in whole or in part, to any other person or entity without the written consent of the Department. The terms of this Contract and such additional terms as the Department may require must be included in any approved subcontract, and approval of any subcontract must not relieve the Provider of any responsibility for performance under this Contract. C. Special Assurances 1. Provider must comply with approved policies and procedures of the Oklahoma Health Care Authority and the Oklahoma Department of Human Services that govern any aspect of service provision. 2. Provider must utilize all other payment resources before this contract can be utilized. Other payment resources include but are not limited to private insurance, Medicare, and Medicaid. Utilization of other payment resources may be monitored at any time. 3. The Provider must act immediately to remedy any situation that poses a risk to the health, well-being or provision of specified services to the member/service recipient. a. In the event of such a threat, the Provider must immediately notify the Oklahoma Department of Human Services of the nature of the situation and must notify the Department upon resolution of the threatening situation. b. The Provider must complete and regularly review incident and injury reports in accordance with OAC 340: The Provider must cooperate with other entities supplying service to persons served through this Contract. 5. Provider must receive reimbursement for providing services to only one member/service recipient at a given time. However, this does not preclude said services from being provided to individuals in group settings i.e., nursing staff supplying three hours of service simultaneously to three member/service recipients may only claim for three hours of reimbursement. 6. The Provider must report all cases of suspected abuse or neglect of children in accordance with Title 10, O.S., Section 7101 et seq. and all cases of suspected abuse, neglect or exploitation of adults in accordance with Title 43A, O.S., Section et seq. 7. The Provider must protect the confidentiality of any member/service recipient served through this contract, and follow all HIPPA guidelines. 5

6 8. The Provider assures reasonable access to its facilities, employees, individuals served, and all records to enable the Oklahoma Health Care Authority, the Oklahoma Department of Human Services and their duly authorized agents to monitor the Provider's compliance with the terms of this contract. 9. The Provider must carry sufficient insurance to indemnify persons for injury to their person or property occasioned by an act of negligence or malfeasance by the Provider. 10. The Provider must refund overpayments to the Oklahoma Health Care Authority within sixty (60) days notification of overpayment. For the purpose of this contract, overpayment will include payment for services not rendered in accordance with the provisions of this contract. If the Provider fails to make a timely refund of overpayment, the Oklahoma Health Care Authority will recoup the amount due from subsequent payments. 11. The parties hereto further agree that fixing the amount of actual damages due the Department of Human Services from Provider for any non-performance of its duties pursuant to this contract would be impracticable and extremely difficult. For that reason, the parties hereto agree that the Department of Human Services, through the Oklahoma Health Care Authority, may, at their sole discretion, deduct an amount not to exceed five percent (5%) of the total amount of this contract as actual damages for each breach or non-performance thereof. Nothing in this provision should be construed as an election of remedies by the Department of Human Services or the Oklahoma Health Care Authority and they must be free to pursue any and all remedies available either in law or in equity. 6