SPECIAL PROVISIONS FOR HOME AND COMMUNITY-BASED SERVICES WAIVER PROVIDERS FOR PERSONS WITH DEVELOPMENTAL DISABILITIES REGISTERED NURSE CLINICAL (RNC)

Transcription

1 SPECIAL PROVISIONS FOR HOME AND COMMUNITY-BASED SERVICES WAIVER PROVIDERS FOR PERSONS WITH DEVELOPMENTAL DISABILITIES REGISTERED NURSE CLINICAL (RNC) 1. PROVIDER is an entity or individual certified by the Oklahoma Department of Human Services (OKDHS) Developmental Disabilities Services Division (DDSD) as eligible to provide services under the Home and Community Based Services (HCBS) Waiver program. 2. PROVIDER agrees that services will be monitored by DDSD and assures reasonable access to its facilities, employees, members, services, and all records to enable OKDHS and its agents to monitor PROVIDER s compliance with this Agreement. 3. Provision of services under this Agreement is limited to persons who have been certified by OKDHS as categorically needy and meet medical criteria for Home and Community Based (HCBS) Services for persons with developmental disabilities. This includes members enrolled in the Living Choice Program who may ultimately be enrolled in the HCBS Waiver. 4. Compensable services are described in Addendum I. To the extent that HCBS are not compensable services, the services may be provided but shall not be compensated by OHCA. Addendum I is made part of this Agreement and incorporated by reference. 5. PROVIDER agrees to submit HCBS service claims to OHCA only: a) For services provided to individuals determined by OKDHS to be eligible for HCBS, except for claims in which eligibility has not been determined and failure to file a timely claim may jeopardize payment; b) In the amount, scope and duration specified in the Individual Plan and for whom they have received authorization from OKDHS; c) After all other insurance or similar sources other than SoonerCare are exhausted; PROVIDER shall bill other resources first. 6. PROVIDER must deliver services in a manner that contributes to the member s enhanced independence, self-sufficiency, community integration and well-being. 7. PROVIDER shall: a) Act immediately to remedy any situation that poses a risk to the health, well-being or provision of specified services to the member; in the event of such a threat, PROVIDER must immediately notify OKDHS of the nature of the situation and must notify OKDHS upon resolution of the threatening situation; b) Cooperate with other entities supplying services to members served through this Agreement; c) Report all cases of suspected abuse or neglect of children in accordance with 10 O.S et seq. and all cases of suspected abuse, neglect or exploitation of adults in accordance with 43A O.S et seq. d) Not provide services that duplicate the services mandated to be provided by the public school district pursuant to the Individuals with Disabilities Education Act; e) Supply services for which the Provider has been determined responsible as reflected in the member s Individual Plan (IP), at those times and places necessary to meet the member s needs. f) If applicable, make reasonable effort to ensure members are afforded freedom of Registered Nurse Clinical

2 choice in all aspects of service provision, for which PROVIDER is responsible, unless such choice jeopardizes the member s independence; 8. OHCA may change Addendum 1 to this Agreement at any time by notification to PROVIDER. No amendment executed by both parties is required for this purpose. 9. This Agreement shall expire October 31, Registered Nurse Clinical

3 ADDENDUM I REGISTERED NURSE CLINICAL MINIMUM QUALIFICATIONS: PROVIDER must be currently licensed in the State of Oklahoma or in the state that services are provided as a registered nurse (RN). DESCRIPTION OF SERVICES: PROVIDER will provide services to eligible members approved to receive DDSD HCBS who reside in community-based settings. Authorized services require a physician s order and must be identified in the member s IP, as developed by their Personal Support Team (Team). Services will be provided contingent upon availability of adequate resources. All nursing services must meet and support criteria to establish service necessity at OAC 340: A summary of the progress on assigned outcomes and action steps, as specified in the member s IP, will be submitted to the member s case manager in accordance with OAC 340: Depending upon the member s medical needs, a combination of nursing services may be required. Nursing services funded through DDSD are as follows: A. 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 members who have health-related issues that are unstable and require skilled treatment or other intervention by a licensed nurse more frequently than three times per day or every two hours; b. ordered by a licensed medical physician, osteopathic physician, physician assistant, or advanced practice nurse; c. provided in accordance with the requirements of OAC 340: ; and d. detailed in the member s Individual plan as well as the Provider s nursing care plan. 2. Extended Duty Nursing Care includes: a. skilled nursing care and interventions rendered directly to the member by the nurse; b. monitoring, evaluation, and documentation of the member s physical or mental status; c. administration of medication or treatments or both as ordered by the licensed medical physician, osteopathic physician, physician assistant or advanced practice nurse; d. documentation of medication or treatment administration, skilled nursing interventions, member 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 during periods skilled nursing tasks and interventions are not being performed. B. Intermittent Skilled Nursing Care Intermittent Skilled Nursing Care involves performance of intermittent skilled tasks or interventions that only a licensed nurse can perform in accordance with 57 Okla. Stat and OAC 340: This service is limited to no more than three intermittent skilled tasks or interventions for any individual member in a 24-hour period. Registered Nurse Clinical

4 1. Intermittent Skilled Nursing Care must be: a. ordered by a licensed medical physician, osteopathic physician, physician assistant, or advanced practice nurse; b. justified in amount by the review performed in accordance with OAC 340: ; and c. detailed in the member s IP as well as PROVIDER s nursing care plan. 2. Intermittent Skilled Nursing Care includes: a. skilled nursing care and interventions rendered directly to the member, as ordered by the licensed medical physician, osteopathic physician, physician assistant, or advanced practice nurse; 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; b. health-related assessments; c. administration of medication or treatments ordered by the licensed medical physician osteopathic physician, physician assistant, or advanced practice nurse; d. documentation of skilled nursing care or interventions, the member 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. C. Individualized Skilled Nurse Training and Evaluation Individualized Skilled Nurse Training and Evaluation provides members with individualized evaluation, monitoring and oversight of health care needs by a licensed nurse and specific, individualized health training by a licensed nurse to the member or the member s family or paid caregivers, in accordance with 56 Okla. Stat and OAC 340: Individualized Skilled Nurse Training and Evaluation services are reimbursed on a 15-minute unit of service basis, with a maximum limit of 16 units per month. Exceptions to this service limitation may be granted if: i. justified in writing by the Team in accordance with OAC 340: ; ii. recommended by the DDSD area nurse manager, and iii. authorized through the tier-review process. The licensed nurse assesses/evaluates the member s training needs prior to initiating competency-based training and develops a nursing care plan 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 56 Okla. Stat Individualized Skilled Nurse Training and Evaluation Services include: 1. Individualized assessment/evaluation oversight of health care needs or individualized access to nurse training or both provided directly to the member, family, or paid caregiver(s), as identified in the member s Individual plan and the Provider s nursing care plan.; 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; Registered Nurse Clinical

5 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; b. the training and capability of the person receiving training; c. the nature of the task being trained; d. the proximity and availability of the licensed nurse to the person when the task is being performed; and 4. Attendance at required meetings as specified in the individual plan. SERVICE REQUIREMENTS A. Services 1. PROVIDER must supply training in accordance with OAC 317: , in individual specific health care practices to the member, the member s family or paid caregivers, regardless of whether or not they are employed by PROVIDER, the member or the member s family. 2. When providing Extended Duty Skilled Nursing care, PROVIDER must perform general care to the member during periods in that skilled nursing tasks and interventions are not being performed. 3. PROVIDER must ensure that all services are rendered in accordance with the Oklahoma Nursing Practice Act, OHCA and the Oklahoma Department of Human Services (OKDHS). 4. 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 preparing DDSD-required reports is compensable. B. Staffing Any registered nursing level of care must be provided by a registered nurse and the service must be provided on site. C. Special Assurances PROVIDER must complete and regularly review incident and injury reports in accordance with OAC 340: Registered Nurse Clinical