Or. Admin. Code § 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 OSBN 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 nursing assessment within 10
business days following the acceptance of a referral. The assessment is defined
in OAR chapter 851, division 006 and regulated by OAR chapter 851, division
045.
(a) The RN must document the nursing
assessment pursuant to OAR chapter 851, divisions 006 and 045.
(b) The RN must send copies of the nursing
assessment to the individual's case manager. If the RN recommends ongoing long
term care community nursing services, the RN must also send a copy of the
Nursing Service Plan as described in section (4) of this rule..
(3) REASSESSMENT. For the purpose
of this rule, the RN must perform a face-to-face reassessment and update the
individual's Nursing Service Plan at a minimum annually. Based on the RN's
assessment of the individual, the RN may determine that an assessment needs to
occur more frequently. Reasons for increased frequency may include, but are not
limited to, a change of condition or change of environment.
(a) The RN must complete the reassessment
within 10 business days of the date the reassessment started.
(b) The RN must document the date, time and
results of the reassessment and 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.
(c) Each reassessment requires the RN to
update the nursing service plan and perform a medication review. The
documentation must support the reason for the re-assessment, have a detailed
description of the activities the RN provided to develop the new nursing
service plan and include detailed information about the changes in the
individual's condition and the scope, duration, and frequency of all nursing
interventions.
(4)
NURSING SERVICE PLAN. Based on the initial assessment or reassessment, the RN
develops or updates the individual's Nursing Service Plan and must:
(a) Prioritize actual or potential client
needs, risk of both;
(b) Identify
expected outcomes for needs and risks identified using quantitative and
qualitative measures of effectiveness;
(c) Establish interventions and strategies
designed to assist the client in attaining expected outcomes and the planned
scope, duration and frequency of each intervention;
(d) Identify implementation, timelines, and
documentation requirements for the plan of care;
(e) Utilize standardized language appropriate
to the context of care;
(f)
Complete and document Nursing Service Plan 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; and
(g) Attend a minimum
of two Nursing Service Plan review meetings each year with an individual's case
manager. This meeting can be held face-to-face, phone or other secure state
approved conference technology.
(5) DELEGATION. The RN must follow the
standards and documentation requirements for delegation of nursing tasks as
required by OAR chapter 851, divisions 006, 045, and 047.
(a) The RN alone, based on professional
judgment and the Oregon Nurse Practice Act regulations, makes the determination
to delegate or not delegate a nursing procedure to a UAP, or to rescind a UAP's
authorization to perform a nursing procedure.
(b) The RN must provide the case manager
with:
(A) An estimate of the number of hours
required for the delegation process;
(B) The individual delegation process needs
identified in the Nursing Service Plan; and
(C) Keep the case manager informed of ongoing
delegation activities on the Nursing Service Summary form (SDS 0752) and
Nursing Service Plan form (SDS 0754).
(c) The RN must keep Medicaid funded home and
community-based setting providers informed through completion of the Nursing
Service Summary form (SDS 0754) for delegation at initial assessment and all
subsequent delegation activities of the delegation decisions and activities
provided to unregulated assistive person..
(6) TEACHING. The RN must follow the
standards and documentation requirements for teaching health promotion as
described in OAR 851-045-0060.
(a) The RN must develop and document a
teaching plan that describes and communicates the reason the teaching is needed
and the specific goals for the individual or the individual's
caregiver.
(b) Teaching related to
non-injectable medications must be provided by an RN in accordance with OAR
chapter 851, division 045 and The Teaching of the Administration of Lifesaving
Treatments specific to intramuscular injections identified in ORS
433.800 through
433.830 must be provided by the
RN in accordance with Oregon Health Authority Training on Lifesaving Treatment
Protocols.
https://www.oregon.gov/oha/ph/providerpartnerresources/emstraumasystems/pages/epi-protocol-training.aspx
(7) MONITORING. The RN must
provide monitoring visits at the individual's home, sufficient in frequency and
duration to implement and keep current 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 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. The 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 needs of the individual or the individual's caregiver. Information
collected and evaluated as part of a medication review may result in changes to
an RN's nursing plan of care, subsequent Teaching Plan or care coordination
activity.
(9) CARE COORDINATION.
The RN provides care coordination in order to advocate for health care services
that an individual needs and to gather the information that is needed to
complete the assessment, nursing service plan or reassessment process, and
medication review. The 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, other nurses, healthcare providers, and
non-caregiving family members or legal representatives.
(10) Time spent completing the services
described in sections (3) through (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(2)(a)(b)
and the Department's Long Term Care Community Nursing Procedure Codes and
Payment Authorization Guidelines.
(11) PRIOR AUTHORIZATION. All long term care
community nursing services in sections (2) through (9) of this rule must be
prior authorized by an individual's case manager.
(a) The RN must use an individual's Nursing
Service Plan to estimate the number of hours needed for long term care
community nursing services within a six month time period. The RN must document
the estimated number of long term care 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 five 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 long term care 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) The
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.
Notes
Statutory/Other Authority: ORS 409.050 & 410.070
Statutes/Other Implemented: ORS 409.010 & 410.070
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