(1) Skilled nursing services are medically necessary services provided directly or indirectly by a registered nurse under an authorizing practitioner's 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. Authorizing practitioner orders must be obtained when required by applicable state practice laws for licensed nurses. Authorizing practitioner orders must be obtained upon initial service, updated when a significant change occurs changing the nursing intervention or at least annually.

(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, maintain function or slow the client's decline of the disease or functional ability. Skilled nursing services are:

(a) Specific to a client's diagnosis;

(b) Individualized to the client with planned measurable outcome goals; and

(c) Reevaluated every ninety days or sooner when there is a significant health change for effect on improvement or maintenance of health status, or slowing the decline of the disease or functional ability.

(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 WAC.

(4) A skilled nursing service is not a qualifying adult day health service merely because the service is ordered by an authorizing practitioner 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, it is not a qualifying adult day health service.

(5) Skilled nursing services must be medically necessary as defined under WAC 182-500-0070. Medically necessary skilled nursing services include but at [are] not limited to:

(a) Assessment, care and evaluation with collaboration of services of an acute or chronic unstable or unpredictable medical condition, with time specific measurable treatment goals, requiring frequent skilled intervention by a registered nurse or by a licensed practical nurse under the supervision of a registered nurse according to WAC 246-840-705 and ordered by the authorizing practitioner;

(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 decubitus ulcers, or other types of wound care.

(e) Provide holistic collaborative care of the client's acute, chronic, unstable or unpredictable medical condition or disease.

(6) Medically necessary skilled nursing services, by way of example, do not include:

(a) Reminding or coaching the client;

(b) Monitoring of a medical condition that does not require frequent skilled nursing intervention or a change in authorizing practitioner 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) ADC 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 182-502-0020.