OAR 411-048-0180
Long Term Care Community Nursing Services
(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 comprehensive nursing assessment as defined in OAR 851-045-0030 (Purpose of Standards and Scope of Practice) within 10 business days following the acceptance of the individual’s referral.(a)
The RN must conduct and document the comprehensive nursing assessment as specified in OAR chapter 851, division 045.(b)
The RN must send copies of the comprehensive nursing assessment to the individual’s case manager. If the RN recommends ongoing long term care community nursing services, the RN must send a Nursing Service Plan as described in section (4) of this rule with the individual’s comprehensive nursing assessment.(3)
REASSESSMENT. The RN must perform a face-to-face reassessment and update the individual’s Nursing Service Plan at least annually and more frequently at the RN’s discretion if the individual experiences a change of condition or change of environment. Based on individual need, the RN must determine if this reassessment is a focused or comprehensive assessment as defined in OAR 851-045-0030 (Purpose of Standards and Scope of Practice).(a)
The RN must conduct and document the comprehensive or focused assessment as specified in OAR chapter 851, division 045.(b)
The RN must complete the reassessment within 10 business days of the date the reassessment started.(c)
The RN must 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.(4)
NURSING SERVICE PLAN. Based on the initial assessment or reassessment, the RN must develop or update the individual’s Nursing Service Plan.(a)
The Nursing Service Plan must describe the needs of the individual and the individual’s caregiver and the specific interventions the RN intends to provide to meet those needs including scope, duration, and frequency.(b)
An RN must complete and document Nursing Service Plans 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.(c)
An RN must attend a minimum of two Nursing Service Plan review meetings each year with a case manager. The RN and the case manager may agree to conduct the Nursing Service Plan review meeting by phone.(5)
DELEGATION. An RN must follow the standards and documentation requirements for delegation of nursing tasks as required by OAR chapter 851, division 047 (Standards for Community Based Care Registered RN Delegation).(a)
The RN alone, based on professional judgment and regulation, makes the determination to delegate or not delegate a nursing task, or to rescind a delegation.(b)
The RN must provide the case manager with an estimate of the number of hours of delegation the individual needs on the Nursing Service Plan and keep the case manager informed of ongoing delegation activities on the Service Summary form.(c)
The RN must keep the adult foster home provider informed of the delegation decisions and activities provided to caregivers in their home.(6)
TEACHING. An RN must follow the standards and documentation requirements for teaching health promotion as described in OAR 851-045-0060 (Scope of Practice Standards for Registered Nurses).(a)
In an overall teaching plan, the RN must describe and document the reason the teaching is needed and the specific goals for the individual or the individual’s caregiver.(b)
An RN must follow the standards for community based care RN delegation in OAR chapter 851, division 047 and the standards for provision of nursing care by a designated caregiver in OAR chapter 851, division 048 when teaching an individual and the individual’s caregiver the nursing tasks needed to meet the individual’s health care needs.(c)
Teaching related to non-injectable medications or anticipated emergencies must be provided by an RN in accordance with OAR chapter 851, division 047 (Standards for Community Based Care RN Delegation).(7)
MONITORING. An RN must provide home based monitoring visits as needed to oversee and implement 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 adult foster home 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. An 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 RN’s judgment and the needs of the individual or the individual’s caregiver. Information gathered as part of a medication review may result in changes to an RN’s Teaching Plan or care coordination activity.(9)
CARE COORDINATION. An RN provides care coordination in order to advocate for health care services that an individual needs and to gather the information that is needed in the assessment or reassessment process, medication review, or Nursing Service Plan implementation. An 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, RNs who provide acute care community nursing services, health care providers, and non-caregiving family members or legal representatives.(10)
Time spent completing the services described in sections (3) to (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 (Requirements for Financial, Clinical and Other Records)(1)(a)(b).(11)
PRIOR AUTHORIZATION. All long term care community nursing services in sections (2) to (9) of this rule must be prior authorized by an individual’s case manager.(a)
An RN must use an individual’s Nursing Service Plan to estimate the number of hours needed for community nursing services within a six month time period. The RN must document the estimated number of 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 5 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 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)
An 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.
Source:
Rule 411-048-0180 — Long Term Care Community Nursing Services, https://secure.sos.state.or.us/oard/view.action?ruleNumber=411-048-0180.