The Oregon Administrative Rules contain OARs filed through November 15, 2015
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DEPARTMENT OF HUMAN SERVICES,
AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES
DIVISION 48
LONG TERM
CARE COMMUNITY NURSING
411-048-0150
Purpose
(1) The rules in OAR chapter 411, division
48 establish standards and procedures for Medicaid enrolled providers who provide
long term care community nursing services. Long term care community nursing services
provide ongoing registered nurse (RN) services to eligible individuals who are receiving
Medicaid home and community-based services in a home-based or foster home setting.
(2) Long term care community
nursing services provide:
(a) Evaluation and identification
of supports that help an individual maintain maximum functioning and minimize health
risks, while promoting the individual's autonomy and self management of healthcare;
(b) Teaching an individual's
caregiver or family that is necessary to assure the individual's health and safety
in a home-based or foster home setting;
(c) Delegation of nursing
tasks to an individual’s caregiver; and
(d) Case managers and health
professionals with the information needed to maintain the individual’s health,
safety, and community living situation while honoring the individual's autonomy
and choices.
Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SPD 8-2013, f. &
cert. ef. 4-15-13; SPD 14-2013(Temp), f. & cert. ef. 7-1-13 thru 12-28-13; SPD
44-2013, f. 12-13-13, cert. ef. 12-15-13
411-048-0160
Definitions
Unless the context indicates otherwise,
the following definitions apply to the rules in OAR chapter 411, division 048:
(1) "AAA" means the Area
Agency on Aging designated by the Department that is responsible for providing a
comprehensive and coordinated system of services to older adults and adults with
disabilities in a designated planning and service area.
(2) "Abuse" means:
(a) Abuse of a child:
(A) As defined in ORS 419B.005;
and
(B) As defined in OAR 407-045-0260,
when a child resides in a foster home licensed by the Department to provide residential
services to a child with intellectual or developmental disabilities.
(b) Abuse of an adult or
older adult:
(A) As defined in ORS 124.050-095
and 430.735–430.765; and
(B) As defined in OAR 407-045-0260
for individuals 18 years or older with intellectual or developmental disabilities
that reside in a Department licensed adult foster home; or
(C) As defined in OAR 411-020-0002
for older adults and adults with a physical disability who are 18 years of age or
older that reside in a Department licensed adult foster home.
(3) "Acute Care Nursing"
means nursing services provided on an intermittent or time limited basis such as
those provided by a hospice agency as defined in ORS 443.850, or a home health agency
as defined in 443.005. Acute care nursing may include direct service and is designed
to address a specific task of nursing or a short term health condition.
(4) "Business Day" means
the day that the "Local Office" is open for business.
(5) "Care Coordination" means
the email, faxes, phone calls, meetings and other types of information exchange,
consultation, and advocacy provided by a registered nurse on behalf of an individual
that is necessary for the registered nurse to conduct assessments, complete medication
reviews, provide for individual safety needs, and implement an individual's Nursing
Service Plan.
(6) "Caregiver" means any
person responsible for providing services to an eligible individual in a home-based
or foster home setting. A caregiver may include an unlicensed person defined as
a designated caregiver in OAR chapter 851, division 48 (Standards for Provision
of Nursing Care by a Designated Caregiver).
(7) "Case Manager" means
a person employed by the Department, Community Developmental Disability Program,
Support Services Brokerage, or Area Agency on Aging who assesses the service needs
of an applicant, determines eligibility, and offers service choices to the eligible
individual. The case manager authorizes and implements an individual's plan for
services and monitors the services delivered.
(8) "CDDP" means the Community
Developmental Disability Program responsible for plan authorization, delivery, and
monitoring of services for individuals with intellectual or developmental disabilities
according to OAR chapter 411, division 320.
(9) "Community Nursing Services"
means "long term care community nursing services" as defined in this rule.
(10) "Delegation" means the
standards and processes described in OAR chapter 851, division 047 (Standards for
Community Based Care Registered Nurse Delegation).
(11) "Department" means the
Department of Human Services or the Department's designee.
(12) "Department Approved
Form" means forms used by registered nurses and case managers to support these rules.
The Department maintains these documents on the Department's website (http://www.oregon.gov/dhs/spd/pages/provtools/nursing/forms.aspx).
Printed copies may be obtained by contacting the Department of Human Services, ATTN:
Rule Coordinator, 500 Summer Street NE, E48, Salem, OR 97301.
(13) "Direct Hands-on Nursing"
means a registered nurse provides treatment or therapies directly to an individual
instead of teaching or delegating the tasks of nursing to the individual's caregiver.
Payment for direct hands-on nursing services is not reimbursed unless an exception
has been granted by the Department as described in OAR 411-048-0170.
(14) "Documentation" means
a written record of all services provided to, and for, an individual and an individual's
caregiver that is maintained by the registered nurse as described in OAR 411-048-0200.
(15) "Enrolled Medicaid Provider"
means an entity or individual that meets and completes all the requirements in these
rules, OAR 407-120-0300 to 0400 (Medicaid Provider Enrollment and Claiming), and
OAR chapter 410, division 120 (Medicaid General Rules) as applicable.
(16) "Foster Home" means
any Department licensed or certified family home in which residential services are
provided as described in:
(a) OAR chapter 411, division
050 for adult foster homes for older adults and adults with physical disabilities;
(b) OAR chapter 411, division
346 for foster homes for children with intellectual or developmental disabilities;
and
(c) OAR chapter 411, division
360 for adult foster homes for individuals with intellectual or developmental disabilities.
(17) "Healthcare Provider"
means a licensed provider providing services such as but not limited to home health,
hospice, mental health, primary care, specialty care, durable medical equipment,
pharmacy, or hospitalization to an eligible individual.
(18) "Home" means a non-licensed
setting where an individual is receiving Medicaid home and community-based services.
(19) "Home and Community-Based
Services" mean the services approved and funded by the Centers for Medicare and
Medicaid Services for eligible individuals who are aged and physically disabled
and for eligible individuals with intellectual disabilities and developmental disabilities
in accordance with Title XIX of the Social Security Act.
(20) "Home Health Agency"
has the meaning given that term in ORS 443.005.
(21) "Individual" means a
person eligible for community nursing services under these rules.
(22) "In-Home Care Agency"
has the meaning given that term in ORS 443.305.
(23) "Local Office" means
the Department office, Area Agency on Aging, Community Developmental Disability
Program, or Support Services Brokerage, responsible for Medicaid services including
case management, referral, authorization, and oversight of long term care community
nursing services in the region where the individual lives and where the community
nursing services are delivered.
(24) "Long Term Care Community
Nursing Services" mean the nursing services provided under these rules to individuals
living in a home-based or foster home setting where the monthly Medicaid home and
community-based services rate does not include nursing services. Long term care
community nursing services are a distinct set of services that focus on an individual’s
chronic and ongoing health and activity of daily living needs. Long term care community
nursing services include an assessment, monitoring, delegation, teaching, and coordination
of services that addresses an individual’s health and safety needs in a Nursing
Service Plan that supports individual choice and autonomy. The requirements in these
rules are provided in addition to any nursing related requirements stipulated in
the licensing rules governing the individual's place of residence.
(25) "Medication Review"
means a review focused on an individual's medication regime that includes examination
of the prescriber's orders and related administration records, consultation with
a pharmacist or the prescriber, clarification of PRN (as needed) parameters, and
the development of a teaching plan based upon the needs of the individual or the
individual's caregiver. In an unlicensed setting, the medication review may include
observation and teaching related to administration methods and storage systems.
(26) "Nursing Assessment"
means one of the following assessments selected by the registered nurse based on
an individual's need and situation:
(a) A "nursing assessment"
as defined in OAR 851-047-0010 (Standards for Community Based Care Registered Nurse
Delegation); or
(b) A "comprehensive assessment"
or "focused assessment" as defined in OAR 851-045-0030 (Standards and Scope of Practice
for the Licensed Practical Nurse and Registered Nurse).
(27) "Nursing Service Plan"
means the plan that is developed by a registered nurse based on an individual's
initial nursing assessment, reassessment, or updates made to a nursing assessment
as a result of monitoring visits.
(a) The Nursing Service Plan
is specific to the individual and identifies the individual's diagnoses and health
needs, the caregiver's teaching needs, and any care coordination, teaching, or delegation
activities.
(b) The Nursing Service Plan
is separate from the case manager's service plan, the foster home provider’s
service plan, and any service plans developed by other health professionals.
(c) Nursing service plans
must meet the standards in OAR chapter 851, division 045 (Standards and Scope of
Practice for the Licensed Practical Nurse and Registered Nurse).
(28) "OSBN" means the Oregon
State Board of Nursing. OSBN is the agency responsible for regulating nursing practice
and education for the purpose of protecting the public's health, safety, and well-being.
(29) "Rate Schedule" means
the communication tool issued by the Department to transmit rate changes to partners,
subcontractors, and stakeholders. The Department maintains this document on the
Department's website (http://www.oregon.gov/dhs/spd/provtools/rateschedule.pdf).
Printed copies may be obtained by contacting the Department of Human Services, ATTN:
Rule Coordinator, 500 Summer Street NE, E48, Salem, OR 97301.
(30) "RN" means a registered
nurse licensed by the Oregon State Board of Nursing. An RN providing long term care
community nursing services under these rules is either an independent contractor
who is an enrolled Medicaid provider or an employee of an organization that is an
enrolled Medicaid provider.
(31) "Support Services Brokerage"
means an entity, or distinct operating unit within an existing entity, that uses
the principles of self-determination to perform the functions associated with planning
and implementation of support services for individuals with intellectual or developmental
disabilities.
(32) "These Rules" mean the
rules in OAR chapter 411, division 048.
Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SPD 8-2013, f. &
cert. ef. 4-15-13; SPD 14-2013(Temp), f. & cert. ef. 7-1-13 thru 12-28-13; SPD
44-2013, f. 12-13-13, cert. ef. 12-15-13; APD 12-2014(Temp), f. & cert. ef.
5-1-14 thru 10-28-14; APD 34-2014, f. & cert. ef. 10-1-14
411-048-0170
Eligibility and Limitations
(1) ELIGIBILITY. Community nursing services
may be provided by an RN to an individual if the individual meets the following
requirements:
(a) The individual must be
determined eligible for Medicaid home and community-based services provided through
the Department;
(b) The individual must be
receiving services through one of the following:
(A) In-home supports for
children with intellectual or developmental disabilities as described in OAR chapter
411, division 308;
(B) Adult foster homes for
individuals with intellectual or developmental disabilities as described in OAR
chapter 411, division 360;
(C) Foster homes for children
with intellectual or developmental disabilities as described in OAR chapter 411,
division 346;
(D) Comprehensive in home
support for adults with intellectual or developmental disabilities as described
in OAR chapter 411, division 330;
(E) Adult foster homes for
older adults and adults with physical disabilities as described in OAR chapter 411,
division 050;
(F) Independent Choices Program
participants as described in OAR chapter 411, division 030;
(G) State Plan personal care
participants as described in OAR chapter 411, division 034;
(H) An individual enrolled
in a brokerage described in OAR chapter 411, division 340;
(I) 1915C Nursing Facility
Waiver; or
(J) State Plan K Community
First Choice;
(c) The individual must live
in a home or a foster home as defined in OAR 411-048-0160;
(d) The individual must be
referred by their case manager for long term care community nursing services. Individuals
may request long term community nursing services through their case manager.
(2) LIMITATIONS.
(a) Long term care community
nursing services may not be provided to:
(A) A resident of a nursing
facility, assisted living facility, residential care facility, 24-hour developmental
disability group home, or intermediate care facility for individuals with intellectual
or developmental disabilities; or
(B) An individual enrolled
in a program or residing in a setting where nursing services are provided under
a monthly service rate.
(b) Case managers may not
prior authorize long term care community nursing services that duplicate nursing
services provided by Medicare or other Medicaid programs.
(c) Long term care community
nursing services do not include nursing activities used for administrative functions
such as protective service investigations, pre-admission screenings, eligibility
determinations, licensing inspections, case manager assessments, or corrective action
activities. This limitation does not include authorized care coordination as defined
in OAR 411-048-0160.
(d) Long term care community
nursing services do not include reimbursement for direct hands-on nursing as defined
in OAR 411-048-0160.
(3) EXCEPTIONS. An exception
to sections (2)(c) and (2)(d) of this rule may be requested as described in OAR
411-048-0250.
Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SPD 8-2013, f. &
cert. ef. 4-15-13; SPD 14-2013(Temp), f. & cert. ef. 7-1-13 thru 12-28-13; SPD
44-2013, f. 12-13-13, cert. ef. 12-15-13; APD 12-2014(Temp), f. & cert. ef.
5-1-14 thru 10-28-14; APD 34-2014, f. & cert. ef. 10-1-14
411-048-0180
Long Term
Care Community Nursing Services
When authorized
by an individual's case manager, the following long term care community nursing
services must be provided by an RN in accordance with these rules and the scope
of practice as stated in the Oregon State Board of Nursing rules in OAR chapter
851.
(1) REVIEW
OF REFERRAL. An RN must screen a referral and notify the individual's case manager
of their decision to accept or refuse the referral within two business days of receiving
the referral on the Department approved form. The RN may refuse any referral.
(2) INITIAL
ASSESSMENT. The RN must perform a face-to-face comprehensive nursing assessment
as defined in OAR 851-045-0030 within 10 business days following the acceptance
of the individual's referral.
(a) The RN
must conduct and document the comprehensive nursing assessment as specified in OAR
chapter 851, division 045.
(b) The RN
must send copies of the comprehensive nursing assessment to the individual's case
manager. If the RN recommends ongoing long term care community nursing services,
the RN must send a Nursing Service Plan as described in section (4) of this rule
with the individual's comprehensive nursing assessment.
(3) REASSESSMENT.
The RN must perform a face-to-face reassessment and update the individual's Nursing
Service Plan at least annually and more frequently at the RN's discretion if the
individual experiences a change of condition or change of environment. Based on
individual need, the RN must determine if this reassessment is a focused or comprehensive
assessment as defined in OAR 851-045-0030.
(a) The RN
must conduct and document the comprehensive or focused assessment as specified in
OAR chapter 851, division 045.
(b) The RN
must complete the reassessment within 10 business days of the date the reassessment
started.
(c) The RN
must send copies of the reassessment to the individual's case manager and include
an updated Nursing Service Plan as described in section (4) of this rule.
(4) NURSING
SERVICE PLAN. Based on the initial assessment or reassessment, the RN must develop
or update the individual's Nursing Service Plan.
(a) The Nursing
Service Plan must describe the needs of the individual and the individual's caregiver
and the specific interventions the RN intends to provide to meet those needs including
scope, duration, and frequency.
(b) An RN
must complete and document Nursing Service Plans on the Department approved form
and provide the Nursing Service Plan to an individual's case manager within 10 business
days of the date that an initial assessment or a reassessment is initiated.
(c) An RN
must attend a minimum of two Nursing Service Plan review meetings each year with
a case manager. The RN and the case manager may agree to conduct the Nursing Service
Plan review meeting by phone.
(5) DELEGATION.
An RN must follow the standards and documentation requirements for delegation of
nursing tasks as required by OAR chapter 851, division 047 (Standards for Community
Based Care Registered RN Delegation).
(a) The RN
alone, based on professional judgment and regulation, makes the determination to
delegate or not delegate a nursing task, or to rescind a delegation.
(b) The RN
must provide the case manager with an estimate of the number of hours of delegation
the individual needs on the Nursing Service Plan and keep the case manager informed
of ongoing delegation activities on the Service Summary form.
(c) The RN
must keep the adult foster home provider informed of the delegation decisions and
activities provided to caregivers in their home.
(6) TEACHING.
An RN must follow the standards and documentation requirements for teaching health
promotion as described in OAR 851-045-0060.
(a) In an
overall teaching plan, the RN must describe and document the reason the teaching
is needed and the specific goals for the individual or the individual's caregiver.
(b) An RN
must follow the standards for community based care RN delegation in OAR chapter
851, division 047 and the standards for provision of nursing care by a designated
caregiver in OAR chapter 851, division 048 when teaching an individual and the individual's
caregiver the nursing tasks needed to meet the individual's health care needs.
(c) Teaching
related to non-injectable medications or anticipated emergencies must be provided
by an RN in accordance with OAR chapter 851, division 047 (Standards for Community
Based Care RN Delegation).
(7) MONITORING.
An RN must provide home based monitoring visits as needed to oversee and implement
an individual's Nursing Service Plan.
(a) The RN
must document the projected frequency of monitoring visits in an individual's Nursing
Service Plan and may adjust the frequency based on the complexity of the Nursing
Service Plan and the individual's needs.
(b) Calls
with adult foster home providers, caregivers, or an individual to review health
status, follow up on instructions, or exchange information related to care coordination
are considered a monitoring visit.
(8) MEDICATION
REVIEW. An RN must provide a medication review during each monitoring visit and
as part of an initial assessment or reassessment. The scope of a medication review
shall be based on the RN's judgment and the needs of the individual or the individual's
caregiver. Information gathered as part of a medication review may result in changes
to an RN's Teaching Plan or care coordination activity.
(9) CARE
COORDINATION. An RN provides care coordination in order to advocate for health care
services that an individual needs and to gather the information that is needed in
the assessment or reassessment process, medication review, or Nursing Service Plan
implementation. An RN uses care coordination to provide updated information to people
involved in an individual’s health care via phone calls, faxes, electronic
mediums, or meetings. Care coordination is provided but not limited to case managers,
RNs who provide acute care community nursing services, health care providers, and
non-caregiving family members or legal representatives.
(10) Time
spent completing the services described in sections (3) to (9) of this rule may
be included in the claim for the respective service but must meet documentation
standards specified in OAR 410-120-1360(1)(a)(b).
(11) PRIOR
AUTHORIZATION. All long term care community nursing services in sections (2) to
(9) of this rule must be prior authorized by an individual’s case manager.
(a) An RN
must use an individual's Nursing Service Plan to estimate the number of hours needed
for community nursing services within a six month time period. The RN must document
the estimated number of community nursing service hours on the Department approved
form for authorization and send the Department approved form for authorization to
the individual's case manager.
(b) The case
manager must authorize the proposed hours after reviewing the individual's completed
Nursing Service Plan. The case manager must complete the prior authorization within
5 business days of receiving the Department approved form for authorization and
the individual's completed Nursing Service Plan.
(12) Prior
authorization for the initial assessment and delegation of services described in
sections (2) and (5) of this rule is granted once the Department approved form for
referral is signed by the RN and the individual's case manager. The payment received
by an RN for initial assessment shall include compensation for all community nursing
services excluding delegation, provided by the RN to the individual and the individual's
caregiver. Payment is not provided until prior authorization as described in section
(11) of this rule has been provided to the RN by the individual's case manager.
(13) An RN
must use the Department approved Service Summary form as the communication tool
for case managers and caregivers to document the monitoring, care coordination,
teaching, delegation, or other services as noted in these rules provided to each
individual.
(14) A local
office manager may grant an exception to the timeframes required in this rule on
a case specific basis.
Stat. Auth.: ORS
410.070
Stats. Implemented:
ORS 410.070
Hist.: SPD
8-2013, f. & cert. ef. 4-15-13
411-048-0190
Communication
and Notification Practices
(1) MANDATORY REPORTING.
An RN must report suspected or known neglect or abuse of all older adults, adults,
and children as required by OSBN and ORS 124.050 to 124.095, 430.735 to 430.765,
and 419B.005 to 419B.045.
(2) CONFIDENTIALITY.
(a) An RN
must adhere to the OSBN confidentiality standards as described in OAR chapter 851
as well as the federal regulations adopted to implement the Health Insurance Portability
and Accountability Act.
(b) An RN
must provide all written, verbal, digital, video, and electronic information regarding
an individual in accordance with the Department's confidentiality parameters as
described in OAR chapter 407, division 014 and the federal regulations adopted to
implement the Health Insurance Portability and Accountability Act.
(3) NOTIFICATION.
(a) An RN
must immediately communicate possible life-threatening health and safety concerns
to:
(A) The local
office protective service worker, worker of the day, or case manager; and
(B) 911,
police, or physician if needed to address emergent or urgent safety concerns.
(b) If while
performing long term care community nursing services under these rules an RN determines
that an individual's health condition is unstable or a significant change of condition
is noted, the RN must either notify the individual's physician or primary care provider
directly or ensure that the individual's caregiver has reported this information
to them.
(c) An RN
must notify the individual's case manager or local office management within one
business day of non life threatening but high risk concerns including changes in
condition as described in subsection (b) of this section, concerns about placement,
or concerns about a caregiver's performance.
(d) An RN
must notify the individual's case manager if the RN becomes aware that an individual
has recently received a significant healthcare intervention such as an emergency
room visit, hospitalization, a change in physician, referral to a specialist, home
health, or hospice.
Stat. Auth.: ORS
410.070
Stats. Implemented:
ORS 410.070
Hist.: SPD
8-2013, f. & cert. ef. 4-15-13
411-048-0200
Additional
Documentation Requirements
(1) An RN must meet
the documentation, record keeping, and communication standards as required by the
Department in addition to the documentation, record keeping, and communication standards
as required by the OSBN in OAR chapter 851. Compliance with these standards ensures
communication between an RN and an individual's case manager and caregiver.
(2) The documentation
standards in this rule and on Department approved forms provided by the Department
do not replace or substitute for the documentation requirements in the:
(a) Rules
for professional nursing standards as prescribed by the OSBN in OAR chapter 851,
divisions 045, 047, and 48;
(b) Medicaid
provider rules governing provider requirements as described in OAR chapter 407,
division 120; and
(c) As applicable,
the Medicaid General Rules described in OAR chapter 410, division 120.
(3) An RN
is expected to complete the Department approved forms specified by the Department
to support the long term care community nursing services in these rules. The Department
may approve the use of alternative but equivalent forms.
(4) An RN
must send copies of the completed Department approved forms to the case manager
prior to or at the time of invoice submission. Documentation must support the long
term care community nursing services billed and adhere to the timeframes noted in
these rules.
(a) An individual's
case manager must receive the required Department approved forms and documentation
to pay a claim.
(b) Failure
to comply with the documentation standards in this rule may result in the determination
of overpayment for which restitution may be sought.
(5) All documentation
must be provided in HIPAA secured format.
(6) The self-employed
RN that is enrolled as a Medicaid provider or an agency enrolled as a Medicaid provider
as described in OAR 411-048-0210 must maintain a record of all long term care community
nursing services provided to each assigned individual and the individual's caregiver.
(a) The record
must include copies of all documentation provided to the local office as well as
any additional documentation the RN or agency maintained to meet OSBN or Medicaid
provider rules.
(b) The RN
must retain the record until the RN no longer provides long term care community
nursing services to the individual, at which time the RN or agency must provide
the individual's case manager a copy of any part of the record not previously provided.
(c) The RN
or agency must retain original records for each individual following HIPAA practices
for a period of seven years.
Stat. Auth.: ORS
410.070
Stats. Implemented:
ORS 410.070
Hist.: SPD
8-2013, f. & cert. ef. 4-15-13
411-048-0210
Qualifications
for Enrolled Medicaid Providers
(1) The Department
may determine the number and type of enrolled Medicaid providers in a geographic
area to assure that there is an appropriate number of qualified enrolled Medicaid
providers to meet the needs of individuals eligible for long term care community
nursing services.
(2) The Department
shall select qualified enrolled Medicaid providers for long term care community
nursing services according to the standards in these rules, OAR 407-120-0320, and
OAR chapter 410, division 120 as applicable.
(3) The long
term care community nursing services provided under these rules may be delivered
by the following enrolled Medicaid providers:
(a) An RN
who is a self-employed provider;
(b) Home
health agencies meeting the requirements in OAR chapter 333, division 027; or
(c) In-home
care agencies meeting the requirements in OAR chapter 333, division 536.
(4) A self-employed
RN who contracts with the Department to provide long term care community nursing
services under these rules must:
(a) Pass
a background check as defined in OAR 407-007-0210; and
(b) Provide
and have available verification of the following:
(A) A current
and unencumbered Oregon Registered RN license;
(B) Certification
of professional liability insurance with coverage that meets Department requirements;
(C) Documentation
supporting qualifications and expertise:
(i) A minimum
of three years experience practicing as an RN in an in-home, home health, skilled
nursing, hospital, or Department licensed community setting. At least one of these
three years must have occurred within three years of the date the RN contracted
with the Department to provide long term care community nursing services.
(ii) Experience
providing nursing delegation or a pass score on the Department's nursing delegation
self study test.
(D) Contact
information for people or entities that verify the qualifications and expertise
documented pursuant to this section.
(c) The RN
must attend a contract briefing session with the local office management to review
contract expectations.
(5) Agencies
listed in section (3)(b) and (c) of this rule who contract with the Department to
provide long term care community nursing services under these rules must:
(a) Maintain
compliance with existing in home or home health agency licensing rules;
(b) Maintain
a separate contract with the Department to provide Medicaid funded in home care
agency services;
(c) Provide
and have available verification of the following:
(A) A current
and unencumbered Oregon Registered RN license;
(B) Certification
of professional liability insurance with coverage that meets Department requirements;
(C) Documentation
verifying the qualification and expertise of the RNs hired by the agency to provide
long term care community nursing services including:
(i) Experience
providing nursing delegation or a pass score on the Department's nursing delegation
self study test;
(ii) Contact
information for people or entities that verify the qualifications and experience
documented pursuant to this section; and
(iii) A background
check as defined in OAR 407-007-0210.
(D) Evidence
of policies and procedures ensuring that the agency and its employees follow the
specific standards in OAR chapter 411, division 048 that may exceed OAR chapter
333, division 536.
Stat. Auth.: ORS
410.070
Stats. Implemented:
ORS 410.070
Hist.: SPD
8-2013, f. & cert. ef. 4-15-13
411-048-0220
Medicaid
Provider Disenrollment /Termination
(1) Enrolled Medicaid
providers of long term care community nursing services, or RN employees of an agency
enrolled as a Medicaid provider providing these long term care community nursing
services may be denied enrollment, terminated, or prohibited from providing long
term care community nursing services for any of the following:
(a) Violation
of any part of these rules;
(b) Violation
of the protective service and abuse rules in OAR chapter 411, division 020 and OAR
chapter 407, division 045;
(c) Any sanction
or action as a result of an OSBN investigation;
(d) Failure
to keep required licensure or certifications current;
(e) Failure
to provide copies of the records described in these rules to designated Department
or Oregon Health Authority entities;
(f) Repeated
failure to participate in Nursing Service Plan review or care coordination meetings
when requested by an individual's case manager;
(g) Failure
to obtain a pass score on the Department's delegation self study test if requested
by the Department;
(h) Failure
to provide services;
(i) Fraud
or misrepresentation in the provision of long term care community nursing services;
(j) Evidence
of conduct derogatory to the standards of nursing as described in OAR 851-045-0070
that results in referral to OSBN; or
(k) A demonstrated
pattern of repeated unsubstantiated complaints of neglect or abuse per OAR chapter
411, division 020 and OAR chapter 407, division 045.
(2) Enrolled
Medicaid providers may appeal a termination of their Medicaid provider number based
on OAR 407-120-0360(8)(g) and OAR chapter 410, division 120 as applicable.
(3) Enrolled
Medicaid providers of long term care community nursing services must provide advance
written notice to the Department at least 30 days prior to no longer providing long
term care community nursing services.
(4) An RN
ending long term care community nursing services must comply with the OSBN's standards
regarding transition of care and transfer or rescinding of delegations per OAR chapter
851, division 47.
Stat. Auth.: ORS
410.070
Stats. Implemented:
ORS 410.070
Hist.: SPD
8-2013, f. & cert. ef. 4-15-13
411-048-0230
Compensation
and Billing
(1) All long term
care community nursing services must be authorized by an individual's case manager
using Department approved forms provided by the Department prior to the delivery
of long term care community nursing services.
(2) All billing
and claims must comply with:
(a) OAR 407-120-0330
and 407-120-0340;
(b) OAR chapter
410, division 120 as applicable; and
(c) The Long
Term Care Nursing Procedure Codes and Payment Authorization Guidelines posted at
http://www.oregon.gov/dhs/spd/pages/provtools/nursing/forms.aspx.
(3) Compensation
for long term care community nursing services in OAR 411-048-0180 shall be defined
in the Department's rate schedule or through a contract with the Department. The
Department may adjust rates in underserved areas to assure that individuals have
access to long term care community nursing services.
(4) Payment
for non-Medicaid covered services must be prior authorized by the Department and
billed on Department approved invoices.
(a) Rates
for non-Medicaid services shall be determined by the Department but may not exceed
the rate noted on the Department's rate schedule.
(b) The Department
makes payment for non-Medicaid covered services within 45 days of receipt of the
completed invoice.
Stat. Auth.: ORS
410.070
Stats. Implemented:
ORS 410.070
Hist.: SPD
8-2013, f. & cert. ef. 4-15-13
411-048-0240
Orientation
Requirements
(1) Self-employed
RN providers as described in OAR 411-048-0210 must attend a total of 12 hours of
office or field based orientation. Field based orientation must be provided by an
experienced RN prior approved by the local office.
(2) Local
office management may authorize additional orientation or field mentorship hours
if mutually agreed upon by the newly contracted RN and the local office manager
(3) Each
RN providing long term care community nursing services as an employee of an agency
as described in OAR 411-048-0210 must attend a total of 12 hours of office or field
based orientation approved by the local office.
(4) Local
office managers may exempt an RN employed by an agency or a self-employed RN provider
from all or part of orientation activities based on written request from the agency
or self-employed RN provider describing an alternative orientation plan. The agreed
upon alternative orientation plan must be signed by either the agency or self-employed
provider and local office management. The local office must provide a copy of the
signed alternative orientation plan to the Department.
Stat. Auth.: ORS
410.070
Stats. Implemented:
ORS 410.070
Hist.: SPD
8-2013, f. & cert. ef. 4-15-13
411-048-0250
Exceptions
(1) The Department
may grant an exception to these rules. Implementation of an exception may not occur
without the Department's written approval.
(2) A request
for an exception to these rules must include but not be limited to the following
standards:
(a) A written
exception request must be provided to central office Department management for prior
approval. The exception request must include;
(A) Local
office management support for the exception request;
(B) A description
of the benefit to the individual served by the Department that may occur as result
of the exception; and
(C) Details
regarding the specific rule for which the exception may be granted, the rationale
for why the exception is needed, the proposed duration of the exception, identification
of alternatives (including rule compliance), and costs of the exception if any.
(b) The exception
may not impact compliance with any rules other than these rules for long term care
community nursing services in OAR chapter 411, division 048.
(c) The exception
may not result in non compliance with the Department's contract standards.
Stat. Auth.: ORS
410.070
Stats. Implemented:
ORS 410.070
Hist.: SPD
8-2013, f. & cert. ef. 4-15-13
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800 Summer St. NE, Salem, Oregon 97310. Any discrepancies with the
published version are satisfied in favor of the Administrative Order.
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