(1) Skilled nursing services are medically necessary services provided directly or indirectly by a registered nurse under physician supervision, or by a licensed practical nurse under physician or registered nurse supervision, that a licensed nurse acting within the scope of practice can provide or supervise. Physician orders must be obtained when required by applicable state practice laws for licensed nurses.
(2) Skilled nursing services must exceed the level of routine health monitoring, general health education, and general therapeutic activities as defined in WAC 388-71-0704
, and must be provided with the reasonable expectation that the services will improve, restore, or maintain function as defined in WAC 388-71-0710
(1)(c). Skilled nursing services are:
(a) Specific to a client diagnosis;
(b) Individualized to the client with planned measurable outcomes; and
(c) Evaluated every ninety days for effect on improvement of health status or prevention of decline.
(3) Skilled nursing services, including the initial client nursing assessment and development of the nursing plan of care, must be provided or supervised by a registered nurse in accordance with nursing practice standards under chapter 246-840
(4) A skilled nursing service is not a qualifying adult day health service merely because the service is ordered by a physician or is provided by a nurse. If, by way of example, the service can be performed by the client or at the client's direction by a person other than a licensed nurse, or the client does not meet eligibility criteria, it is not a qualifying adult day health service.
(5) Skilled nursing services must be medically necessary as defined under WAC 388-500-0005
. Medically necessary skilled nursing services may, but do not necessarily, include:
(a) Care and assessment of an unstable or unpredictable medical condition, with time limited measurable treatment goals, requiring frequent intervention by a registered nurse or by a licensed practical nurse under the supervision of a registered nurse according to WAC 246-840-705
(b) Evaluation and management of the care plan when unstable medical conditions or complications require complex nonskilled care and skilled nurse oversight to ensure that the nonskilled care is achieving its purpose;
(c) Time-limited training by licensed nursing staff to teach the client and/or the client's caregiver self-care for newly diagnosed, acute, or episodic medical conditions that require the skills of a licensed nurse to teach, and that will optimize client function, as illustrated by the following examples:
(i) Self administration of an injection;
(ii) Prefilling insulin syringes;
(iii) Irrigating a catheter;
(iv) Caring for a colostomy or urostomy;
(v) Wound dressing changes or aseptic technique; or
(vi) Disease self-management.
(d) Skilled interventions provided directly by a licensed nurse such as:
(i) Inserting or irrigating a catheter;
(ii) Administering medications or oxygen;
(iii) Administering and managing infusion therapy; or
(iv) Treating decubitis ulcers, or other types of wound care.
(6) Medically necessary skilled nursing services, by way of example, do not
(a) Reminding or coaching the client;
(b) Monitoring of a medical condition that does not require frequent skilled nursing intervention or a change in physician treatment orders, or where there is no reasonable expectation that skilled services will maintain, improve, or slow the effect of a progressive disabling condition on the pain, health or functioning of a client;
(c) Medication assistance when the client is capable of self-administration or is having this need met through paid or unpaid caregivers;
(d) Evaluation and management of the care plan when the complexity of care to be provided by nonskilled persons does not require skilled nurse oversight beyond routine health monitoring;
(e) Continued training by nursing staff to teach self-care for newly diagnosed, acute, or episodic medical conditions when it is apparent that the training should have achieved its purpose or that the client is unwilling or unable to be trained;
(f) Core services that can be provided by an adult day care center, such as routine health monitoring, general health education, or general therapeutic activities; or
(g) Group therapy or training where three or more clients are being simultaneously treated or trained by the nurse.
(7) Skilled nursing services must be documented as provided under WAC 388-71-0746
and chapter 388-502
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.04.200, 74.08.090, 74.09.520, and 74.39A.030. 03-06-024, § 388-71-0712, filed 2/24/03, effective 7/1/03.]