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Title XIX Nursing Care Level Determination Guideline

PDF Version of BQA 03-007 (PDF, 29 KB)

DATE: December 8, 2003 DSL-BQA-03-007
Replaces BQA Memo 99-068

TO: Nursing Homes NH 04

FROM: Michael J. Steinhauer, Resident Care Review Section, Bureau of Quality Assurance

via: Susan Schroeder, Director, Bureau of Quality Assurance

The Bureau of Quality Assurance (BQA) utilizes statutory and administrative code definitions as the basis for Title XIX nursing care level determinations.

There have recently been questions raised related to intensive skilled nursing services (ISN) determinations. The most commonly asked questions relate to continuous oxygen administration, sliding scale insulin regimens and activities of daily living (ADL) dependency.

Consistent with Chapter 50 language, BQA does not automatically determine an ISN care level when a person is receiving continuous oxygen or is on a sliding scale of insulin. Likewise, BQA does not require ADL dependency to qualify for an ISN care level.

This memo is intended to clarify issues and provide guidance to facility and Bureau staff in care level determination. If you have any questions, please contact your Regional Field Operations Director listed below:

Dolores Zwiers
Regional Field Operations Director
Northeastern (Green Bay) Regional Office
(920) 448-5249

Joanne Powell
Regional Field Operations Director
Northern (Rhinelander) Regional Office
(715) 365-2802

Patricia Benesh
Regional Field Operations Director
Southeastern (Milwaukee) Regional Office
(414) 227-4908

Juan Flores
Regional Field Operations Director
Southern (Madison) Regional Office
(608) 243-2374

Joe Bronner
Regional Field Operations Director
Western (Eau Claire) Regional Office
(715) 836-4753

Title XIX Nursing Care Level Determination Guideline

Purpose and Intent:

These guidelines are intended to assist the evaluator in the determination of Title XIX care levels. These care levels are required to be determined on all Title XIX residents who reside in Wisconsin licensed nursing homes or in Intermediate Care Facilities for Mentally Retarded (ICFs/MR) persons.

The request for Title XIX Care Level Determination (Form DSL-2256) is completed and submitted to the local Regional Bureau of Quality Assurance office along with a complete Minimum Data Set (MDS) or Level of Care Determination Worksheet (Form DSL-2288).

A determination of the care level is made at the time of admission to a Title XIX certified long-term care facility, or if already a resident, when the person becomes eligible for Title XIX. Changes to an initial determination may be made as a result of a facility-submitted request or annual survey care level review.

The care level is utilized for authorization for payment. The Bureau of Quality Assurance (BQA) notifies Electronic Data System Federal (EDS) of all Title XIX resident care level determinations.

These guidelines are for the purpose of clarifying, defining, and interpreting the factors to be considered in setting the care level. While these guidelines describe distinct care level categories, there must be enough flexibility to allow unusual combinations to be dealt with from a total resident perspective.

Intensive Skilled Nursing Services – ISN

"Intensive skilled nursing care" means care requiring specialized nursing assessment skills and the performance of specific services and procedures that are complex because of the resident's condition or the type or number of procedures that are necessary, including any of the following: (a) Direct patient observation or monitoring or performance of complex nursing procedures by registered nurses or licensed practical nurses on a continuing basis. (b) Repeated application of complex nursing procedures or services every 24 hours. (c) Frequent monitoring and documentation of the resident's condition and response to therapeutic measures.

Services that likely qualify as ISN when provided in conjunction with the above definition:

  • Enteral/parenteral nutritional services, unless independently performed.
  • Ventilator and complex respiratory services (excluded services are aerosol therapy, spirometers and postural drainage and nebulized aerosol drug therapy. Also excluded is routine continuous O2 therapy without complex procedures/services).
  • Tracheotomy care services.
  • Complex ostomy care.
  • Intense medication regimen requiring assessment, monitoring and documentation of resident’s response. This would include sliding scale insulin when used on a frequent/continuous basis to attain glycemic control.
  • Complex/wound skin management.
  • Peritoneal dialysis.

Skilled Nursing or Rehabilitation Services – SNF

Skilled nursing services means services that are provided to a resident under physician's orders, to which all of the following apply: (a) The services require the skills of and are provided directly by or under the supervision of a person whose licensed, registered, certified or permitted scope of practice is at least equivalent to that of a licensed practical nurse. (b) Any of the following circumstances exist: 1. The inherent complexity of a service prescribed for a resident is such that it can be safely and effectively performed only by or under the supervision of registered nurses or licensed practical nurses. 2. The full recovery or medical improvement of the resident is not possible, but the services are needed to prevent, to the extent possible, deterioration of the resident's condition or to sustain current capacities of the resident. 3. Because of special medical complications, performing or supervising a service that is generally unskilled or observing the resident necessitates the use of a person whose licensed, registered, certified or permitted scope of practice is at least equivalent to that of a licensed practical nurse.

Skilled rehabilitation services means those services furnished pursuant to a physician's orders which require the skills of a physical therapist, occupational therapist, speech pathologist or audiologist and which are provided either directly by or under the supervision of the professional personnel. Skilled rehabilitation services shall be provided at least five (5) sessions a week.

Services that may qualify as skilled nursing services:

  • Assessment and management of changing health status.
  • Intravenous, intramuscular, or subcutaneous injections and hypodermoclyses or intravenous feedings.
  • Insertion, sterile irrigating, and replacement of catheters.
  • Treatment of wounds, decubitus ulcers or other widespread skin disorder.
  • Rehabilitation nursing procedures.

Services that may qualify as skilled rehabilitation services:

  • Ongoing assessment of rehabilitation needs and potential.
  • Therapy services provided by or under the direct supervision of the therapist, at least five (5) sessions a week. This may be one therapy or any combination of therapies to total five (5) sessions a week.

Intermediate Nursing Care – ICF 1

Basic nursing care includes physical, emotional, social, and other restorative services under periodic medical supervision. This nursing care requires the skill of the registered nurse in assessment, observation and documentation of reactions and symptoms, and supervision of nursing care. Most of the residents have long-term illnesses or disabilities, which may have reached a relatively stable plateau. Other residents whose conditions are stabilized may need medical and nursing services to maintain stability. Essential supportive consultant services are provided.

Services that may qualify as ICF 1 services:

  • Assessment and management of care.
  • Prophylactic and palliative skin care.
  • Routine or stable ostomy care.
  • Evaluation and monitoring of occasional lab or special tests.
  • Provisions are made for periodic medical supervision and structured environment.

Intermediate Nursing Care – ICF 2

Limited nursing care includes care procedures required by residents with long-term illnesses or uncomplicated disabilities in order to maintain stability and which can be provided safely only by or under the supervision of a person no less skilled than a licensed practical nurse who shall be under the direction of a registered nurse. Supervision of the physical, emotional, social and restorative needs of the resident shall be under the appropriate medical supervision.

Services that may qualify as ICF 2 services:

  • Assessment and management of care.
  • Caring for residents where no rapid change is expected in the resident’s condition.
  • Nursing measures taken require infrequent modification because of the resident’s relatively stable physical and mental condition.
  • The services are directed toward personal care, supervision and protection.

No Care Level

A no care level designation means a resident does not meet any of the above nursing care levels. Residents determined to be no care level do not qualify for Medical Assistance payments for nursing home care.

Intermediate Nursing Care – ICF 3

Personal care means personal assistance, supervision and suitable activities programs. The services provided are chiefly characterized by the fact that they can be provided by personnel other than those trained in medical or allied fields. The medical service emphasizes a preventive approach of medical supervision by the resident physician as part of a formal medical program that will provide required consultation services and also cover emergencies. The dietary needs of residents are met by the provision of an adequate general diet or by therapeutic, medically prescribed diets. Activity programs, embracing a wide variety of activities to meet individual need, receive a major emphasis.

Intermediate Nursing Care – ICF 4

Residential care provides social service and activity therapy services for residents with these needs as distinguished from nursing needs. Medical services are provided as needed. Residents retained are at least independently mobile.

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