Or. Admin. Code § 411-380-0030 - Eligibility and Limitations for Direct Nursing Services
(1) NON-DISCRIMINATION. An individual may not
be denied direct nursing services or otherwise discriminated against on the
basis of race, color, religion, sex, gender identity, sexual orientation,
national origin, marital status, age, disability, source of income, duration of
Oregon residence, or other protected classes under federal and Oregon Civil
Rights laws.
(2) ELIGIBILITY. To be
eligible for direct nursing services, an individual must meet the following
requirements:
(a) Be 21 years of age or
older.
(b) Be an Oregon resident
who meets the residency requirements in OAR
461-120-0010.
(c) Be determined eligible for developmental
disabilities services by a Community Developmental Disabilities Program in the
county of origin as described in OAR
411-320-0080.
(d) Be receiving one of the following:
(A) A Medicaid Title XIX benefit package
through OSIPM or HSD medical programs. Individuals receiving Medicaid Title XIX
through HSD medical programs for services in a nonstandard living arrangement
as defined in OAR 461-001-0000 are subject to the
requirements in the same manner as if the individual requested these services
under OSIPM, including the rules regarding:
(ii) The equity value of a home which exceeds
the limits as set forth in OAR
461-145-0220.
(B) A benefit package through the
Healthier Oregon medical program.
(e) Be determined to meet the ICF/IID Level
of Care as defined in OAR
411-317-0000.
(f) Based on a functional needs assessment,
require oversight for complex health management support needs.
(g) Score 45 or higher on the Direct Nursing
Services Criteria completed by the Department.
(h) Have health impairments requiring
long-term direct nursing services determined medically necessary and
appropriate based on the order of a physician.
(3) ACUITY LEVELS. The amount of hours
available for direct nursing services is based on the following acuity levels
as measured by the Direct Nursing Services Criteria:
(a) Level 1: Score of 75 or above and on a
ventilator for 20 hours or more per day = up to a maximum of 554 hours per
month for direct nursing services.
(b) Level 2: Score of 70 or above = up to a
maximum of 462 hours per month for direct nursing services.
(c) Level 3: Score of 65 to 69 = up to a
maximum of 385 hours per month for direct nursing services.
(d) Level 4: Score of 60 to 64 = up to a
maximum of 339 hours per month for direct nursing services.
(e) Level 5: Score of 50 to 59 or if an
individual requires ventilation for sleeping hours = up to a maximum of 293
hours per month for direct nursing services.
(f) Level 6: Score of 45 to 49 = up to a
maximum of 140 hours per month for direct nursing services.
(4) SERVICE DELIVERY.
(a) Except as limited under section (5)(a) of
this rule, direct nursing services may be delivered at the following:
(A) An individual's home.
(B) An adult foster home as described in OAR
chapter 411, division 360.
(C) A
licensed 24-hour residential setting as described in OAR chapter 411, division
325.
(D) An employment setting as
described in OAR chapter 411, division 345.
(E) A day service site.
(F) In the community.
(b) The hours for direct nursing services for
individuals accessing other attendant care services at an employment setting or
in the community, are prorated based on the acuity level of the individual
between the employment setting and the home of the individual.
(5) LIMITATIONS.
(a) Direct nursing services are excluded for
the following:
(A) An individual while in a
medical or psychiatric hospital.
(B) An individual residing in a school,
nursing facility, assisted living facility, or residential care
facility.
(b) Direct
nursing services may not substitute for, or duplicate, other direct or private
duty nursing services provided by State Plan or third party
resources.
(c) Direct nursing
services provided concurrently with hospice services provided under OAR
410-142-0240 or home health care
services provided under OAR
410-127-0040 are not
reimbursable under these rules.
(d)
Direct nursing services are not covered in conjunction with any intravenous,
enteral, or parenteral related skilled nursing services as described in OAR
410-148-0300.
(e) Direct nursing services may not duplicate
school-based nursing services covered under the provision of the Individuals
with Disabilities Education Act (IDEA).
(f) Direct nursing services do not include
any of the following:
(A) Hours spent
receiving professional training or career development.
(B) Administrative functions such as
non-individual-specific services, quality assurance reviews, authoring health
related agency policies and procedures, or providing general training for
caregivers.
(C) Travel time spent
in transit to or from the residence of the provider.
(D) Long-term care community nursing
services, including nurse delegations, as described in OAR chapter 411,
division 048.
Notes
Statutory/Other Authority: ORS 409.050, 413.085, 427.104 & 430.662
Statutes/Other Implemented: ORS 409.010, 413.085, 427.007, 427.104, 430.610 & 430.662
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