Medicaid Service Update

To:  ADvantage Case Management, Home Care and Assisted Living Providers

Subject:  ADvantage Nursing Service Guidelines

Date:  January 3, 2023

The Medicaid Services Unit (MSU) would like to take this opportunity to explain processes, define service codes, clarify the role of provider nurses, and provide guidance for best practices in caring for ADvantage Members in all areas related to nursing.

Per the Oklahoma Board of Nursing (OBN) Patient Assessment Guidelines, the Comprehensive Nursing Assessment by the Registered Nurse (RN) is defined as an extensive data collection (initial and ongoing) that addresses anticipated and emergent changes in the Member's health status, recognizes alterations from the Member's previous condition, synthesizes the biological, psychological and social aspects of the Member's condition, evaluates the impact of nursing care, and uses this broad and complete analysis to develop the nursing plan of care, which includes communication and consultation with other health team members (National Council of State Boards of Nursing, 2014). 

The OBN Patient Assessment Guidelines defines the Focused Assessment by the Licensed Practical Nurse (LPN) as an appraisal of an individual’s status and situation at hand, contributing to the comprehensive assessment by the RN, supporting initial and ongoing data collection and deciding who needs to be informed of the information and when to inform (National Council of State Boards of Nursing, 2014).

Simply put, the RN conducts a comprehensive assessment of the ADvantage Member and assists the Case Manager in the development of the person-centered service plan.  The LPN may contribute to the assessment of the Member by conducting a focused assessment and recommending changes to the service plan as necessary.  

Rules and Responsibilities Specific to ADvantage

• Per Oklahoma Department of Health (DOH) policy 310:662-5-2(a), Plan of care – Non-skilled care:
  • If only personal care is provided, the ...registered nurse shall prepare a plan of care at the time of initial assessment.
  • The plan of care shall be developed after consultation with the Member and/or the Member's representative and shall include potential services to be provided; the frequency of visits and/or hours of service; as well as identified problems, method of intervention, and date of resolution.
  • The plan of care for the Member shall be communicated to the caregiver prior to or at the time of the delivery of non-skilled care.
  • The plan of care shall be revised as necessary, but it shall be reviewed and updated by the registered nurse and all appropriate staff involved in care delivery at least every six (6) months.
    • While the six (6) month supervisory visit may be completed by an LPN, the LPN is responsible for tagging the RN supervisor to request review of the nursing assessment documentation.
    • The RN is responsible for reviewing the LPN’s documentation and marking the LPN’s “Visit Completed” note as “Read.” Marking the note as “Read” is the equivalent of the co-signature of the RN. 

Per DOH policy 310:662-5-3(h). Supervision of services: 

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  • When only home health aide or personal care services are furnished to a Member, a physician or a licensed nurse shall make a supervisory visit to the Member's residence at least once every six (6) months.
    • Note the responsibilities of the LPN and RN as stated in the previous section.
  • The frequency of supervisory visits shall be increased if the acuity of the Member's illness requires more frequent visits.
• Per ADvantage Service Standards for Advanced Supportive/Restorative Assistance, the RN must (not an inclusive list):
  • Conduct an initial assessment visit and develop the plan of care for Members with Advanced Supportive/Restorative Care needs, in collaboration with the Case Manager.
  • Attend IDT meetings to establish or amend the Plan of Care.
  • For all Advanced Supportive/Restorative (ASR) Care Members:
    • Conduct on-site visits at six-month intervals.
    • During the visit, the RN shall conduct an evaluation of the adequacy of the authorized services to meet the needs and conditions of the Member and shall assess the Advanced Supportive/Restorative Care Aides' ability to carry out the authorized services.
  • For all Advanced Supportive/Restorative (ASR) Care Assistants:
    • Observe the successful execution by the aide of each Advanced Supportive/Restorative Care task during an on-the-job training session and certify the successful completion of the task in the aide's personnel record. This visit may be authorized and reimbursed.
• The LPN may conduct the quarterly-authorized nurse visits to evaluate the condition of the Advanced Supportive/Restorative Care Member.
• The LPN may complete the six-month assessment visit for Members who are NOT receiving ASR services.
  • As noted previously, the LPN must complete a Note advising the six-month assessment visit has been completed, tagging the RN supervisor to request review of the nursing assessment documentation.  The RN is responsible for reviewing the LPN’s documentation and marking the LPN note as “Read.”
• Either the RN (G0299) or LPN (G0300) may complete Skilled Nursing or Extended Skill Nursing visits, as determined by the Registered Nurse and documented in the Member’s person-centered service plan.

Please refer to the following table for an at-a-glance explanation:

 Please Note:  There is no change to the nursing requirements for State Plan Personal Care. (T1001 – Nursing Assessment/Evaluation).

Home Care Transfers for G0299/G0300 Services

• When transferring a Member to a new Home Care provider for existing Skilled Nursing services (G0299/G0300) requiring a physician’s order:
  • Existing Skilled Nursing services will not be ended until the new home care provider has obtained an order for Skilled Nursing. 
    • It is the responsibility of the new Home Care provider to obtain the physician’s order for Skilled Nursing services.
    • Neither the existing Home Care provider nor the Case Manager may obtain the physician’s order for the new Home Care agency.
  • The outgoing provider should continue to provide services to the Member to ensure there is no break in service.
  • Once the new provider has submitted the physician’s order:
    • The new provider will be authorized to begin providing services on the Monday following the date of processing by MSU. 
    • The existing provider authorizations will end the Sunday before.
    • This process will help to avoid any break or overlap in service.

Home Care Transfers for G0299/G0300 Services (continued)

• If the Home Care provider selected by the Member does not have staff to provide needed G0299/G0300 skilled nursing services, an alternate provider may be selected.
  • In other words, the Home Care provider and the Skilled Nursing provider do not have to be the same agency except for supervision of Personal Care/ASR Assistants. 

Best Practices:

• A maximum of eight (8) units per day of Registered Nursing services (T1002) for Member assessment and participation in the IDT meeting for service plan development may be authorized.
  • If at all possible, the IDT meeting should be scheduled to occur immediately after the nurse assessment visit, allowing approximately four to five (4 to 5) units for the assessment.
  • Regardless of when the IDT meeting occurs after the T1002 visit has been completed, the Case Manager should facilitate service plan development for personal care and any health related/medical needs at the beginning of the meeting to make the best use of the RN’s time.
  • The RN may leave the IDT meeting after collaboration and development of the Member’s service plan for personal care and health related/medical needs has been completed.
  • If additional units are needed for the above activities beyond those authorized and not exceeding the eight units per day maximum, the RN should request the Case Manager add those units to the Member’s service plan for authorization.
• When requesting G0299 or G0300 on the service plan, the request should:
  • Be submitted in a yearly frequency to prevent billing issues for the Home Care provider.

Provide details of the nursing tasks to be completed and frequency for each task in the Comments area.

Conflict Free Case Management:

As a reminder, the Centers for Medicare and Medicaid Services (CMS) Final Rule regarding Conflict Free Case Management for Home and Community Based Services (HCBS) §441.301(c)(1)(vi) states that “Providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide case management or develop the person-centered service plan.” 

This rule prevents a Case Manager from serving a Member who receives home care or assisted living services from a provider where the Case Manager is also employed as an RN, even if the Case Manager is not acting as the RN for the Member.  For example:

• RN Case Manager Jane Smith is employed by ABC Case Management Agency.
• Jane Smith is also employed part-time as an RN by XYZ Assisted Living Center where she works every other weekend.
• The Member lives in XYZ Assisted Living Center.
• Jane Smith may not serve as the case manager for the Member due to a conflict of interest.

This rule also prevents a Case Manager who is related to a Member from providing case management services to that Member.  For example:

• RN Case Manager Joe Brown works for ABC Case Management Agency.
• Joe Brown is the nephew of an ADvantage Member assigned to ABC Case Management Agency.
• Joe Brown may not serve as the case manager for the Member due to a conflict of interest.

Thank you for your commitment to provide quality services to Members of the ADvantage Waiver. We appreciate you and your dedication to Oklahoma’s vulnerable adults.  We hope this information has clarified the roles of the ADvantage nurses.  If you have any questions regarding the information provided above, please feel free to contact us via Harmony Provider Question.     

COMMUNITY LIVING, AGING AND PROTECTIVE SERVICES (CAP)
MEDICAID SERVICES UNIT (MSU)
ADvantage Administration | State Plan Care Unit | Medical Eligibility Services
Office: 918-933-4900 | CareLine: 800-435-4711