D.C. Mun. Regs. tit. 29, § 1931
1931.1 The purpose of this section is to establish standards governing Medicaid eligibility for skilled nursing services under the Home and Community-Based Services Waiver for Individuals with Intellectual and Developmental Disabilities (Waiver) and to establish conditions of participation for providers of skilled nursing services.
1931.2 Skilled nursing services are medical and educational services that address healthcare needs related to prevention and primary healthcare activities. These services include health assessments and treatment, health related trainings and education for persons receiving Waiver services and their caregivers.
1931.3 To be eligible for Medicaid reimbursement, the person shall exhaust all available skilled nursing visits provided under the State Plan for Medical Assistance (Medicaid State Plan) prior to receiving skilled nursing services under the Waiver.
1931.4 To be eligible for Medicaid reimbursement, the person shall have a condition of circulatory or respiratory function complications, gastrointestinal complications, neurological function complications, or the existence of another severe medical condition that requires monitoring or care at least every other hour.
1931.5 To be eligible for Medicaid reimbursement, skilled nursing services shall:
(a) Be ordered by a physician when it is reasonable and necessary to the treatment of the person's illness or injury, and include a letter of medical necessity, a summary of the person's medical history and the duties that the skilled nurse would perform; and a skilled nurse checklist; and
(b) Authorized in accordance with each person's Individual Support Plan (ISP) and Plan of Care after all Medicaid State Plan skilled nursing visits have been exhausted.
1931.6 The physician's order described in Subsection 1931.5 shall include the scope, frequency, and duration of skilled nursing services, shall be updated at least every ninety (90) calendar days, and shall be maintained in the person's records.
1931.7 In order to be eligible for Medicaid reimbursement, the duties of a registered nurse (RN) delivering skilled nursing services shall be consistent with the scope of practice standards for registered nurses set forth in § 5414 of Title 17 of the District of Columbia Municipal Regulations (DCMR). They may include, at a minimum, but are not limited to the following duties:
(a) Performing a nursing assessment in accordance with the Developmental Disabilities Administration's Health and Wellness Standards;
(b) Assisting in the development of the Health Care Management Plan (HCMP);
(c) Coordinating the person's care and referrals;
(d) Administering medications and treatment as prescribed by a legally authorized healthcare professional licensed in the District of Columbia or consistent with the requirements in the jurisdiction where services are provided;
(e) Administering medication or oversight of non-licensed medication administration personnel;
(f) Providing oversight and supervision to the licensed practical nurse (LPN), when delegating and assigning nursing interventions;
(g) Providing updates to Department on Disability Services (DDS) every sixty (60) days, if there are any changes to the person's needs or physician's order;
(h) Training the person, LPN, family, caregivers, and any other individual, as needed; and
(i) Recording progress notes during each visit and summary notes at least quarterly.
1931.8
In order to be eligible for Medicaid reimbursement, the duties of an LPN delivering skilled nursing services shall be consistent with the scope of practice standards for a licensed practical nurse set forth in Chapter 55 of Title 17 of the DCMR. They may include, at minimum, but are not limited to the following duties:
(a) Completing the quarterly reports which shall be reviewed and approved by the supervising RN;
(b) Immediately reporting, immediately, any changes in the person's condition, to the supervising registered nurse;
(c) Providing wound care, tube feeding, diabetic care, and other treatment regimens prescribed by the physician; and
(d) Administering medications and treatment as prescribed by a legally authorized healthcare professional licensed in the District of Columbia. If services are provided in another jurisdiction, the services shall be consistent with that jurisdiction's requirements.
1931.9 Medicaid reimbursable skilled nursing services shall be provided by an RN or LPN under the supervision of an RN, in accordance with the standards governing delegation of nursing interventions set forth in Chapters 54 and 55 of Title 17 of the DCMR.
1931.10 In order to be eligible for Medicaid reimbursement, each person providing skilled nursing services shall:
1931.11 In order to be eligible for Medicaid reimbursement, each home health agency providing skilled nursing services shall comply with Section 1904 (Provider Qualifications) and Section 1905 (Provider Enrollment Process) of Chapter 19 of Title 29 of the DCMR.
1931.12 To be eligible for Medicaid reimbursement, skilled nursing services shall have prior authorization from DDS.
1931.13 In order to be eligible for Medicaid reimbursement, the RN shall monitor and supervise the provision of services provided by the licensed practical nurse, including conducting a site visit at least once every thirty (30) days, or more frequently, if specified in the person's ISP.
1931.14 The RN shall ensure that the person's clinical record includes notes that are clearly written and contain a statement of the person's progress or lack of progress, medical conditions, functional losses, and treatment goals that demonstrate that the person's services are and continue to be reasonable and necessary.
1931.15 In order to be eligible for Medicaid reimbursement, each provider shall maintain records pursuant to the requirements described under Section 1908 (Reporting Requirements) and Section 1909 (Records and Confidentiality of Information) under Chapter 19 of Title 29 of the DCMR.
1931.16 In order to be eligible for Medicaid reimbursement, each home health agency
providing skilled nursing services shall ensure that the LPN receives ongoing supervision and that the service provided is consistent with the person's ISP.
1931.17 Each skilled nursing provider shall review and evaluate skilled nursing services provided to each person, at least quarterly. The skilled nursing provider shall also maintain a contingency plan that describes how skilled nursing will be provided when the scheduled nurse is unavailable; and, if the lack of immediate care poses a serious threat to the person's health and welfare, how the service will be provided when back-up staff are unavailable.
1931.18 Services shall only be authorized for Medicaid reimbursement in accordance with the following provider requirements:
1931.19 Medicaid reimbursement for skilled nursing services is only available for individuals who live independently in their natural homes or host homes, and shall not be available when provided in a residential habilitation or supported living setting.
1931.20 Medicaid reimbursement is not available under the Waiver for skilled nursing visits that exceed fifty-two (52) visits per person annually.
1931.21 Upon exhaustion of the hours available for skilled nursing services under the Medicaid State Plan, Medicaid reimbursement may be available for one-to-one extended nursing services for twenty-four (24) hours a day, up to three hundred and sixty-five (365) days, with prior approval from DDS, for persons on a ventilator or requiring frequent tracheal suctioning.
1931.22 Prior approval for one-to-one extended nursing services shall be obtained from the Medicaid Waiver Supervisor or designated DDS staff person after submission of documentation demonstrating the need for the extended services.
1931.23 Medicaid reimbursement governing the provision of skilled nursing services shall
be developed using the following two (2) rate structures:
(a) Skilled nursing services rate; and
(b) Extended skilled nursing services rate.
1931.24 The Medicaid reimbursement rate for skilled nursing services shall be sixty-five dollars ($65.00) per visit for services provided by an RN or LPN for four (4) hours or less in duration. The Medicaid reimbursement rate for extended RN visits shall be thirty-two dollars ($32) per hour or eight dollars ($8) per fifteen minutes for extended RN visits for four (4) hours or less in duration. The Medicaid reimbursement rate for extended LPN visits shall be twenty dollars ($20.00) per hour or five dollars ($5) per fifteen minutes for extended visits for four (4) hours or less in duration.
1931.25 A provider shall provide at least eight (8) minutes of service in a span of fifteen (15) continuous minutes to be able to bill a unit of service.
SOURCE: Final Rulemaking published at 61 DCR 2615 (March 28, 2014).