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Frequently Asked Questions

Introduction

These frequently asked questions (FAQs) are designed to answer questions from case managers (CM) about the Long Term Care Community Nursing (LTCCN) Program and are written as if asked by a CM. I​n addition, some questions are written from the provider perspective and those are also answered and included in this update.

The questions and answers are interpretation of policy to help clarify general questions in order to provide a better understanding of the program. If there is need for additional clarification or policy direction, please contact the LTCCN Program Coordinator. The FAQs are not necessarily updated with any policy changes.


  
Question
Answer
Eligibility and Services

How do I know if a person is eligible to receive Long Term Care Community Nursing services?

Individuals must be eligible for either an APD or DD waiver and receive services in the following settings or programs: In-Home Services; Comprehensive In-Home Support for Adults with Developmental Disabilities; Adult Foster Homes for Person with Developmental Disabilities; Foster Homes for Children with Developmental Disabilities, Adult Foster Homes for Aging or Persons with Physical Disabilities, Independent Choices, or State Plan Personal Care Services.  Settings such as ventilator homes where persons receive nursing as part of a contracted or enhanced rate would not be eligible.

Eligibility and Services

Is an individual who receives State Plan Personal Care (SPPC) services eligible for LTCCN RN services? 

Yes, SPPC participants are eligible to receive LTCCN services, if they meet the other eligibility requirements in OAR 411-048-0170. 

Eligibility and Services

When should I make a referral?​

The following section identifies reasons why a referral may be made to a nurse.  Services are expected to be provided in a person centered manner including the individual with a focus on promoting self-management of the health condition(s) whenever possible. Items marked with an * indicate situations where the physician should be informed by the nurse, foster home provider or case manager of the change in health status. 

  • Need for consumer, family member or care provider education
  • Delegation is needed for a nursing care task.  Nursing care tasks are defined as tasks that are taught in Schools of Nursing and not performed by the general population. After an assessment, the nurse would be expected to either ‘teach’ family members or the individual to perform the nursing task or ‘delegate’ the task to a paid care provider. The nurse will need to follow this case as long as the delegation is in effect.
  • Medication safety issues or concerns.
  • *Unexpected increased use of emergency care, physician visits or hospitalizations. RNs can help the caregivers and case manager evaluate the placement and ensure that the caregivers have the skills they need to meet the individual’s needs.  When this situation occurs with an individual who already has a nurse, the nurse may need to do a Reassessment and provide an updated Nurse Service Plan.  
  • *Changes in behavior or cognition. A RN can help the caregivers or individual communicate in a manner to ensure the primary care physician receives relevant information, PRN parameters are clearly understood and that medications are not used as chemical restraints or for caregiver convenience. The nurse can assist the caregivers in developing a positive behavior support plan if the person does not have a Behavior Consultant or a mental health provider. Individuals who are assessed as a full assist in cognition may need this type of referral.
  • *Nutrition, weight, or dehydration issues. RNs can help the caregivers or individual communicate effectively to ensure that physicians and registered dieticians receive relevant information. .  The nurse can assist the caregiver and individual with identification of strategies to help promote adherence to a therapeutic lifestyle and dietary orders. 
  • ​*Pain Issues. The RN can help the caregivers or individual communicate effectively  to ensure the primary care provider has all relevant information related to the underlying potential causes of the pain.  The RN can provide teaching on the basics of pain management, including administration of pain medications, use of PRN medications, safe management of narcotics, assessment of interventions, use of pain severity scales and how to report pain related issues/concerns.
  • *History of recent, frequent falls. The RN would be expected to examine the reason for the falls, provide a safety assessment of the home, educate the individual and/or caregivers about mobility safety, fall prevention, when to access medical care and when to access 911 services. The RN can help the caregivers or individual communicate effectively to ensure the primary care provider has all relevant information related to the falls.  
  • ​*Potential for skin breakdown or recently resolved skin breakdown. LTCCN RNs would not be used to manage complex wound care or deteriorating skin conditions, such as advanced pressure ulcers.  A LTCCN referral may be done if the caregivers or individual need help with ongoing interventions designed to prevent future problems or maintain a stabilized skin condition.  
  • Not following medical advice.   If an individual refuses ordered treatments, medications or therapies , all parties (nurse, caregiver, foster home provider, case manager and primary care provider) need to closely coordinate and ensure the individual understands the risks.  A LTCCN referral may be helpful in these situations, as a nurse may help the individual identify and communicate what is preventing him or her from following through with the needed interventions.  Through teaching, the nurse can help identify solutions to provide the individual with more acceptable interventions. Nurses may refuse to accept or continue with the case unless there is a strong team approach and it’s clear that the individual can provide informed consent. 

Eligibility and Services

Can individuals receive LTCCN services if they have no caregivers? 

Individuals may receive teaching and nursing supports if they are in any of the eligible benefit programs.  Most persons who are in these programs require supports from family members, friends or paid caregivers, however an eligible individual without caregivers may receive LTC Community Nursing services. 

Eligibility and Services

Can individuals receive LTCCN services while they are in a hospital or nursing home? 

It depends on whether the case manager has ended their Home and Community Based Care (HCBC) benefit.  If a person the nurse has been seeing has to go to another care setting, the nurse should check with the case manager to see if they should continue to provide Care Coordination, transition/discharge planning etc while the individual is in the hospital.  If the HCBC benefit has been closed, the LTCCN RN cannot be paid for services, so in most cases this will not be allowed.

Eligibility and Services

​​Can an individual decline RN services?

An individual with the ability to make an informed decision has the right to decline RN services. If the case manager feels that the individual's decision to decline LTCCN RN services jeopardizes their health and safety then you must communicate these concerns to their manager.   In some situations this decision may create the need for a new placement if the absence of nursing supports will create licensing problems for the foster home provider or a significant deterioration in the individual’s health status.

Referral Process

​​When should I make a referral?  

The following section identifies reasons why a referral may be made to a nurse.  Services are expected to be provided in a person centered manner including the individual with a focus on promoting self-management of the health condition(s) whenever possible. Items marked with an * indicate situations where the physician should be informed by the nurse, foster home provider or case manager of the change in health status. 

  • Need for consumer, family member or care provider education
  • Delegation is needed for a nursing care task.  Nursing care tasks are defined as tasks that are taught in Schools of Nursing and not performed by the general population. After an assessment, the nurse would be expected to either ‘teach’ family members or the individual to perform the nursing task or ‘delegate’ the task to a paid care provider. The nurse will need to follow this case as long as the delegation is in effect.
  • Medication safety issues or concerns.
  • *Unexpected increased use of emergency care, physician visits or hospitalizations. RNs can help the caregivers and case manager evaluate the placement and ensure that the caregivers have the skills they need to meet the individual’s needs.  When this situation occurs with an individual who already has a nurse, the nurse may need to do a Reassessment and provide an updated Nurse Service Plan.
  • ​*Changes in behavior or cognition. A RN can help the caregivers or individual communicate in a manner to ensure the primary care physician receives relevant information, prn parameters are clearly understood and that medications are not used as chemical restraints or for caregiver convenience. The nurse can assist the caregivers in developing a positive behavior support plan if the person does not have a Behavior Consultant or a mental health provider. Individuals who are assessed as a full assist in cognition may need this type of referral.
  • *Nutrition, weight, or dehydration issues. RNs can help the caregivers or individual communicate effectively to ensure that physicians and registered dieticians receive relevant information. .  The nurse can assist the caregiver and individual with identification of strategies to help promote adherence to a therapeutic lifestyle and dietary orders. 
  • *Pain Issues. The RN can help the caregivers or individual communicate effectively  to ensure the primary care provider has all relevant information related to the underlying potential causes of the pain.  The RN can provide teaching on the basics of pain management, including administration of pain medications, use of PRN medications, safe management of narcotics, assessment of interventions, use of pain severity scales and how to report pain related issues/concerns.
  • *History of recent, frequent falls. The RN would be expected to examine the reason for the falls, provide a safety assessment of the home, educate the individual and/or caregivers about mobility safety, fall prevention, when to access medical care and when to access 911 services. The RN can help the caregivers or individual communicate effectively to ensure the primary care provider has all relevant information related to the falls.  
  • *Potential for skin breakdown or recently resolved skin breakdown. LTCCN RNs would not be used to manage complex wound care or deteriorating skin conditions, such as advanced pressure ulcers.  A LTCCN referral may be done if the caregivers or individual need help with ongoing interventions designed to prevent future problems or maintain a stabilized skin condition.  
  • Not following medical advice.   If an individual refuses ordered treatments, medications or therapies, all parties (nurse, caregiver, foster home provider, case manager and primary care provider) need to closely coordinate and ensure the individual understands the risks.  A LTCCN referral may be helpful in these situations, as a nurse may help the individual identify and communicate what is preventing him or her from following through with the needed interventions.  Through teaching, the nurse can help identify solutions to provide the individual with more acceptable interventions. Nurses may refuse to accept or continue with the case unless there is a strong team approach and it’s clear that the individual can provide informed consent. 

Referral Process

How do I make a referral?

Each local office has local procedures and protocols that case managers need to follow. All LTCCN RNs are required to have an active secure email account and be available by phone.

  • When contacting the prospective RN, have the LTC Community Nursing Service Plan Referral (SDS 0753) filled in as much as possible so you can provide the RN with pertinent information about the individual. The CM should sign the SDS 0753 before sending it to the LTC Community Nurse Provider. It is helpful if you provide them with a copy of the CAPS intake assessment/service plan. A referral for “ongoing monitoring” is not a sufficient reason for a LTCCN RN referral. 
  • The provider must notify you within two business days of their decision to accept or deny the referral.
  • Once the CM and provider have signed the LTC Community Nursing Service Plan Referral (SDS 0753) the provider has the prior authorization to provide the initial assessment and delegation services.
  • It is highly recommended to set up an appointment to review the completed service plan at the time the provider accepts the referral.  Service plans need to be reviewed with the case manager who coordinates the individual’s services.  
  • Retain a copy of the completed SDS 0753 for the individual's file documenting the provider’s decision. This will serve as the legal record demonstrating that the provider accepted the referral and begins the timeline to ensure that that individual receives the needed service.
  • Remember, Medicaid requires that these file be available for seven years from the service end date.  

Referral Process

​​What happens after the LTCCN RN accepts the referral?

The RN must complete an assessment  within 10 business days following the acceptance of the referral and a Nursing Service Plan within 10 business days of the date that an initial assessment or a reassessment is initiated. The nurse must meet with you to discuss the completed assessment and Service Plan. The RN and the CM may mutually agree to conduct the Nursing Service Plan review meeting in person or by phone. During this meeting, you and the RN will discuss their observations, the Service Plan, visitation plan and Prior Authorization request. The goals of the program are that a majority of individuals will be seen by the nurse; the completed Nursing Service Plan is reviewed by you and the nurse; and the visitation plan hours are authorized within 20 business days of the referral date.  Completion within 30 days of the referral is acceptable. Nurses and case managers are expected to communicate with each other if they cannot meet these timeline. Management should be notified if the timeframe management is a persistent challenge.

Referral Process

Can I obtain a LTCCN RN referral for an emergency or unexpected placement when the individual will need delegation services? 

The RN program is not an emergency service, so this workforce is not available to support placements outside of the referral process noted above.  Foster home providers cannot accept individuals receiving Medicaid benefits without case manager authorization. The pre-admission screening required of foster home providers should include determination of what nursing services they will need. They cannot admit the individual until these services are in place.  If the individual is discharging from a hospital stay, his or her home health benefit can cover delegation until a LTCCN RN accepts the referral. 

Referral Process

​​What if there are no LTCCN RNs available to accept the referral?

Individual access to the program is limited by the availability of nurses. If there are no other available RNs in your county that are able to accept the referral, there are a couple of options to consider:

  • ​​The Nursing Program Coordinator in your county can contact an adjacent county to see if they have excess nurse capacity.  A RN can accept a referral from anywhere in the state that they are willing to travel. If the two offices agree to share a nurse then they must notify the LTCCN Program Coordinator in Salem to discuss documentation and reimbursement information. 
  • The individual's care provider(s) can receive direct training on how to perform the task for the individual from the individual's medical practitioner as an alternative to nursing delegation.
  • The individual may have a family member who is willing to perform the ‘nursing task’ for the individual.
  • The individual’s health provider or managed care plan can be contacted to provide nursing services.
  • Individuals without need for RN delegation may have to have to have their nursing service reduced or stopped so that their nurse can be reassigned to the individual with a higher care need.
  • County Developmental Disabilities Programs are expected to contract with nurses for their populations if there are no existing nurses with the skills to serve this population.  The local APD/AAA is expected to provide assistance with processing the prior authorizations and access to all RN trainings and communications. 
Referral Process

Can a LTCCN RN decline a referral?

As independent Medicaid providers, a self-employed RN or In-Home/Home Health agency contracted to provide LTC Community Nursing Services can decline referral for reasons related to workload, geographic location, placement setting or medical condition. However once they have accepted a referral and developed a service plan they cannot drop the case without notifying you and assisting in an orderly transfer to a new nurse.

Referral Process

How will the referral process work with an In-Home/Home Health agency that is contracted to provide LTC Community Nursing Services?  


With LTCCN referrals to In-Home/HH agencies, the agency itself is responsible to accept or decline the referral.  The agency will then decide which of its qualified employees to assign to the individual.  As part of the local office and agency agreement, the agency will need to notify the local office the name and contact information of the nurse assigned to the individual.  If the agency nurse is on short vacation or ill, the agency would assign a back-up nurse. If the agency nurse resigns, or is on an extended leave, the agency would notify the local office, and work together to reassign a different agency nurse to the case, notifying the local office who the replacement nurse is. 

Referral Process

What should happen if the self-employed RN or agency RN gets to the individual’s home and decides that the situation is not safe?


 It is important for the contractor to understand that billing for services can only occur when nursing services have been provided.  Based on the RN initial assessment, the RN can determine the individual’s needs and identify potential safety issues. If the contractor were to go out and consider a situation unsafe, the contractor would need to notify the CM immediately who can reexamine the placement and supports. The CM would then confer with their manager, and notify the LTCCN Program coordinator.  Before the case would be considered for reassignment, the local office and program coordinator would need to meet.  A pattern of refusing individuals before or after the initial assessment may be a contract issue.

Referral Process

Can an individual decline RN services?

An individual with the ability to make an informed decision has the right to decline RN services. If the case manager feels that the individual's decision to decline LTCCN RN services jeopardizes their health and safety then you must communicate these concerns to their manager.   In some situations this decision may create the need for a new placement if the absence of nursing supports will create licensing problems for the foster home provider or a significant deterioration in the individual’s health status.  

Long Term Care Community Nursing Services

What kinds of nursing services are provided by a LTC Community RN?

Registered Nurse services provided under this program focus on teaching and supporting the person or the person’s  caregivers to ensure that the person’s health needs are supported.  These nurses do not duplicate or replace the nursing services provided through home health, hospice, hospital or other clinical settings.  While the LTCCN RN may be teaching or delegating caregivers to provide direct hands on nursing tasks LTCCN RNs cannot provide these tasks themselves. The nursing services they provide include:

  • Review of referrals from case managers.
  • An assessment of an individual's ongoing health support needs.
  • Based on this assessment the nurse creates a nursing service plan which describes the activities they will provide to address these needs. All plans must include a medication review.
  • This plan must include an estimate of the hours of specific services they will need the case manager to prior authorize.
  • Provide the referring case manager with ongoing nursing service summaries documenting the monitoring, teaching and/or delegation, and care coordination activities they have provided.
Long Term Care Community Nursing Services

​​What services cannot be provided by a LTC Community Nurse? 

The RN cannot provide the following services:

  • Delegations to support unscheduled/emergency placements. This is not a crisis service.
  • Management of medically unstable or fluctuating conditions that are unpredictable or which require frequent or ongoing nurse assessment or judgment 
  • Medical or health care services in lieu of those that should be provided by a medical provider or other licensed or certified practitioner.
  • Direct hands-on nursing care or an ongoing nursing task cannot be performed except in isolated situations that are prior authorized by management at both the local and state levels. 
  • Transporting individuals in their cars.
  • Administration activities such as corrective action, licensing, protective services investigations, individual welfare checks, nursing facility pre-admission screenings, eligibility determinations,  rate setting or case management services.  
  • An audit, review or to "check up" on the services provided by another RN. However, nurses may be assigned and paid as mentors for newly contracted nurses with authorization by central office.
  • Case manager assessments.  However nurses who have completed an initial assessment and nursing service plan on an individual may be asked by the case manager to participate in interdisciplinary planning or to consult on development of a placement plan.
  • Attending medical appointments or coordination of medical services unless prior authorized by a case manager.  If the nurse is going to provide this type of medical support services the case manager must provide clear documentation why either the foster home provider, paid caregiver or Oregon Health Plan provider cannot provide these supports.  These coordination activities should be listed on the Nursing Service Plan.

Long Term Care Community Nursing Services

What should a RN Nursing Assessment tell me?

The nursing assessment is the nursing process used to collect information about your individual and their living environment.  At a minimum the nursing assessment should review:

  1. The individual's health support needs related to both the reason and other known health conditions.
  2. Any environmental concerns that prevent challenges to health or safety
  3. The individual's key health beliefs and health behaviors including behaviors that create potential and current risk to the individual.
  4. Any teaching or delegation needs that need to be addressed.  

Long Term Care Community Nursing Services

Is there a form for the RN Assessment? 

Since nursing assessment is part of the practice of nursing that is dictated by the State Board of Nursing we do not provide the nurses with a required form.  The Board of Nursing has detailed standards regarding what is covered and what must be documented.  RN’s can use tools of their choice to comply with this basic nursing practice but must attach for the case manager the following information: 

  • Identification that the document is a RN Assessment
  • Identification of to whom the Assessment was distributed and date of distribution
  • Demographics of the individual (Name, address, I.D. number, etc)
  • Summary statements in layperson language of the findings regarding the four issues noted above 
  • Name of the Long Term Care Community RN and In-Home/HH Agency if applicable
  • Date of the evaluation

This information is attached to the Nursing Service Plan.   If the nurse determines that based on the assessment that the individual does not need RN services the nurse must be paid for the time spent making this determination and the Assessment documentation can be attached to the original referral since there will be no Nursing Service Plan.  

Long Term Care Community Nursing Services

​​How often should a Reassessment be done? 

The LTCCN 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.

Long Term Care Community Nursing Services

​​What should a Nursing Service Plan tell me? 

The APD Long Term Care Community Nursing Service Plan (SDS 0754) is a required form designed to communicate to the case manager the individual’s current needs and the specific services and activities that the RN will be providing to your individual. This form provides you with the information you need to review the Prior Authorization request. The service plan will include the frequency of Monitoring Visits, whether Delegation is needed, and the estimated service units for Delegation.  The service plan should be updated to reflect current individual conditions and nursing services and should have enough detail that it supports the services noted on the Nursing Services Summary (SDS 0752) sent to you after each visit.  The Plan should be typed or legible and must be individualized to the individual.  

Long Term Care Community Nursing Services

Can the LTCCN RN and Case Manager review service plans over the phone? 

Face to face meetings are optimal for the six month Nursing Service Plan reviews of nursing service plans especially if either the individual or the nurse is new to the case manager, however the LTCCN RN and CM may mutually agree to conduct the review by phone.   A face to face meeting ensures that you and the nurse have a common understanding of the individual’s needs and how the nurse plans to meet these needs.  It is easier to ask the nurse for clarification or additional information if the meeting is face to face. 

Long Term Care Community Nursing Services

What should the CM do if they don’t understand or agree with the Service Plan?

The Nursing Service Plan should never contain medical or nursing jargon, technical terms or abbreviations.  Authorizing the services your individual needs is your job and you have the legal responsibility to ensure that the amount and types of services are necessary.  Nurses in this program are expected to be able to teach lay persons about health needs and activities. If they cannot clearly explain to you in a respectful manner what the individual needs and how they will be addressing these needs, then it’s doubtful that they will be effective with caregivers and individuals.  If you have questions regarding the amount of service that a nurse is proposing and they do not help you understand why they need the proposed hours, then you should immediately review the situation with your manager.

Long Term Care Community Nursing Services

What is a RN Medication Review?

All LTCCN RNs are expected to provide a Medication Review for the individuals they are assigned. Nurses are not expected to duplicate the functions of a prescriber or pharmacist but rather focus on an assessment of the individual or the caregiver’s ability to safely administer medications. The Board of Nursing rule OAR 851-047 provides guidance to nurses regarding documentation and standards regarding teaching of non-injectable medications.  If a nurse is concerned about the type, dosage or frequency of a medication order they are expected to bring the problem to the attention of the pharmacist or prescriber.  The individual or caregiver should be a part of this communication. 

A medication review should occur each time the nurse visits the individual.  The purpose is to check on the individual’s or caregiver’s ability to:  obtain medication and medication refills; safely take their medications as ordered; recognize and report desired medication outcomes and undesirable side effects or adverse drug reactions to their PCP or prescriber; and to store their medications safely. The review should result in either:

  • ​A confirmation that the individual or caregiver is using or administering their medications safely.
  • A plan to address specific educational needs of the individual and/or the individual's caregivers unsafe medication usage/practices. This plan should address actual or perceived barriers that prevent the individual from correctly taking their medication and identification of the consequences of the non- compliance. 
  • Review of any PRN orders to make sure that the instructions and parameters are defined and understood by the person administering the medication.  The nurse is expected to provide direction regarding PRN that are supported by licensing standards in that setting. 

Oregon nursing law requires that RNs report unsafe medication administration practices that are not corrected by their teaching activities to the licensing agency that has authority over the setting where the unsafe practice is occurring. It is important that you and the nurse both understand your local process for communication of these concerns.  

If a RN is working with an individual who is receiving home health or hospice services then one of the critical coordination issues is to determine which RN is providing holistic medication reviews.  If the LTCCN RN coordinates with the hospice or home health nurse and learns the hospice or home health nurse is only focusing on medications provided for the problems they are addressing e.g. pain management or post hospital treatment, then the LTCCN RN should document this coordination and continue on with their holistic medication reviews.  

Long Term Care Community Nursing Services

Are there guidelines for the frequency of Monitoring Visits?

The RN should make decisions regarding the frequency of Monitoring visits and type of contact based on the Nursing Service plan and the needs of the individual and caregivers. The LTCCN RN uses the Nursing Service Plan (SDS 0754) to communicate the frequency of monitoring visits to the CM. 

Long Term Care Community Nursing Services

When can LTCCN RN services be stopped?


If an individual has been in the program for more than a year and the Nursing Service plan provided to you at the six month prior authorization meetings indicates that individual has no changes in their medical conditions then it is reasonable to begin discussion with the nurse about whether a teaching plan can be implemented to begin to phase out the nursing supports. Such a teaching plan could include identification of situations that would indicate the caregiver should call the case manager and request resumption of services.  If the individual needs continued delegation this approach may not be possible. 

Long Term Care Community Nursing Services

As the LTCCN RN, I often determine that an individual requires medical supplies and work with the physician to obtain a prescription and work with the medical vendor/supplier to be sure the individual receives the appropriate supplies.  Is this an appropriate activity for a LTCCN RN?


One of the goals of LTCCN program is for the nurse to identify and evaluate supports that help an individual maintain maximum functioning, while minimizing health risks and promoting the individual’s autonomy and self-management of healthcare. A primary focus of the program is for the LTCCN RN to provide teaching and delegation to the individual, their caregivers, or their family to allow self-management of healthcare.  If the nurse identifies a need for the individual, it is important the nurse support and teach the individual or care provider to notify the physician and convey what support is needed, and also support and teach the individual or care provider how to work with the medical vendor/supplier to ensure the individual receives the appropriate supplies.     

Long Term Care Community Nursing Services

​​What should I do if I think the RN is not providing services to the individual? 

Once you have authorized the LTCCN RN to implement the Nursing Service Plan, the RN provider has a legal responsibility to do so. If the RN is unable to implement the authorized plan for any reason, it is his/her responsibility to notify you immediately. Failure to do so could constitute individual abandonment and must be reported to local management as soon as you are aware of the problem.

Delegation/Teaching

​​What Is Delegation? 

Delegation of a nursing task is a legal procedure overseen by the Board of Nursing (OAR 851-047). Delegation means the nurse provides training and supervision to ensure that the individual receives safe ongoing provision of a specific nursing task by a qualified caregiver.  ‘Nursing’ tasks are activities that must be delegated if performed by non- family members without a nursing license.  Tasks might include subcutaneous insulin injection, tracheotomy care and suctioning, and the administration of nutritional supplements, medications and hydration through a gastrostomy tube.  Nurses have sole authority whether to perform delegation or not and it must be limited to individuals with stable health conditions.  Each delegation is performed by a specific nurse and is focused on a specific task, delivered by a specific caregiver to a specific individual. The delegation process must be restarted if any of these components changes (the task, the caregiver, the individual or the nurse).  Nurses are expected to use forms of their choice to document delegation and teaching activities.

Delegation/Teaching

What is the difference between teaching and delegation?

Teaching is a much broader range of activities that can be provided to a group of care givers or to an individual.  Teaching can be specific to a person or a health condition.  Teaching can be provided to one or a group of caregivers.  Teaching can support a range of tasks that individuals may need to prevent, minimize or manage a health problem. Examples of teaching tasks include administration of oral medications, capillary blood glucose (CBGs) levels or transfer techniques. Nurses who provide teaching must be aware of and uphold the licensing standards of the setting where the individual lives. Although teaching can be informal and provided whenever a nurse is in an individual’s home there should also be a goal, strategy and end date so that the nurse and the case manager can determine if the teaching is effective.  If there is no impact on the individual or caregiver as a result of the teaching and no further strategies can be identified then the nursing service may need to be discontinued.    

Long Term Care Community RN Coverage

Can RNs transfer cases to another RN?

Under no circumstance can a LTCCN RN transfer a case directly to another RN. Case managers must authorize each RN working with an individual through the individual referral process.  If a RN is going on vacation they might indicate to the case manager a particular RN that can be contacted in their absence but the case manager has to be involved and authorize the nurse through the referral process to provide services. If an RN no longer can provide services to an individual then the case manager needs to be notified to help ensure that a new RN is identified and to oversee the transition of the case. 

When an In-Home or HH agency is providing Long Term Care Community Nursing Services, the agency itself is responsible to ensure continued nursing services. If the agency nurse is on vacation, ill or on an extended leave, the agency would notify the local office, and inform the local office who the replacement nurse is.  

Long Term Care Community RN Coverage

​​As an In-Home/Home Health agency, if we accept an individual, we do it as an agency and assign it to the right staff member. How will that process work with an agency that is contracted to provide LTC Community Nursing Services?  

With LTCCN referrals to In-Home/HH agencies, the agency itself is responsible to accept or decline the referral.  The agency will then decide which of its qualified employees to assign to the individual.  As part of the local office and agency agreement, the agency will need to notify the local office the name and contact information of the nurse assigned to the individual.  If the agency nurse is on short vacation or ill, the agency would assign a back-up nurse. If the agency nurse resigns, or is on an extended leave, the agency would notify the local office, and work together to reassign a different agency nurse to the case, notifying the local office who the replacement nurse is. 

Long Term Care Community RN Coverage

​​Can individuals refuse to work with specific RNs? 

Referrals should take into account individual choice and preference. In-home individuals may refuse the nursing service but case managers should work closely with them to explain the risk to their ongoing participation in the in-home program and the impact on their health and safety.

Long Term Care Community RN Coverage

Can foster home providers request or refuse to work with specific RNs?

Foster home providers need to assure that nursing services are provided to the individuals they accept.  LTCCN RNs and foster home providers are expected to have a professional partnership. Case managers should attempt to find a nurse who can foster this partnership, however foster home providers must work with available nursing resources to meet their licensing requirements and the individual’s needs.  

Long Term Care Community RN Coverage

​​What do I need to do if a RN tells me that s/he can no longer provide services to my individual?

If a RN gives you this notice you will need to determine if your individual needs to be referred to another RN and if so, how quickly. If the nurse is unable to continue to provide services due to concerns over the individual’s health and safety or caregiver/placement abilities than you will need to reexamine the placement plan as well as address the individual’s need for nursing supports.  Nurses who are leaving a case are expected to provide you with as much information as you need to support the transition to a new nurse and can be paid for coordination with the new nurse and the individual or caregivers. 

Long Term Care Community RN Coverage

​​When can RN services be stopped?

If an individual has been in the program for more than a year and the Nursing Service plan provided to you at the six month prior authorization meetings indicates that individual has no changes in their medical conditions then it is reasonable to begin discussion with the nurse about whether a teaching plan can be implemented to begin to phase out the nursing supports. Such a teaching plan could include identification of situations that would indicate the caregiver should call the case manager and request resumption of services.  If the individual needs continued delegation this approach may not be possible. 

Prior Authorization (PA)

If ongoing RN services are needed by my individual, how do I authorize those services? 

If ongoing RN services are needed by your individual, it is the LTCCN RNs responsibility to request prior authorization (PA) of those services from you. To request ongoing RN services, the RN will present you with a completed Prior Authorization (PA) for APD Long Term Care Community Nursing (SDS 4102) form. This form will contain the procedure codes and total services units that the RN expects to use.   The PA request form must have a current Nursing Service Plan attached and the nurse will not be paid for services rendered before the date that the PA form is signed.  

To authorize the PA request, you sign the completed SDS 4102 form. Services can be authorized for up to six months.  If you want to have more contact with a RN and to review the case more frequently then you can authorize services for a shorter period.  

Prior Authorization (PA)

​​Can I deny a Prior Authorization Request?

As the individual's case manager, you have the authority to deny a LTCCN RNs PA request. Reasons a case manager may choose to not prior authorize or discontinue RN services could include:

  • The nurse has submitted an incomplete or inaccurate SDS 4102 form. 
  • The PA request does not have a current Nursing Service Plan attached.
  • The attached Nursing Service Plan appears to be incomplete or inaccurate. 
  • The PA services that are requested by the RN do not match the services recorded on the Nursing Service Plan or the individual’s needs.
  • The services identified on the Nursing Service Plan are outside of the services allowed per 411-048-0000 through 411-048-0130
  • The individual does not appear to need continued RN Services.  If the nurse claims that ‘nothing has changed’ then a discussion should occur as to whether the hours of service can be reduced or what is the justification for continuing the RN visits?
  • The services recorded on the Nursing Service Plan do not include RN delegation and you and your manager have decided to place this individual on a waiting list for continued services. 
  • The individual has requested another nurse and the change appears to be in the individual’s best interest. 

Prior Authorization (PA)

​​What are the essentials of Prior Authorization?

A review of the individual’s current and complete Nursing Service Plan (SDS 0754) with the RN must occur when you sign a Prior Authorization request.  You have five business days to enter the PA information into the MMIS system so that the nurse can bill for services they provide.  Services cannot be delivered prior to the date you sign the PA request form.

Prior Authorization (PA)

​​Where is the "original" Prior Authorization kept? 

The PA signed by the CM should be kept in the individual file, as the CM is the one that authorizes the PA.  A copy of that PA can be provided to the contractor, however please refer to APD AR-13-090 for detailed information on how the contractor receives notice of a PA authorization.

Prior Authorization (PA)

​​Can I back date a Prior Authorization Request?

No.  Prior Authorization means that you must review and sign this form before the RN delivers the services.  Backdating Prior Authorization forms can only be done in exceptional situations and will require manager and LTCCN Program Coordinator approval and documentation of the circumstances.  

Prior Authorization (PA)

​​Can I provide Prior Authorization for more than one nurse per individual? 

Yes.  In order to provide continuity of care to an individual when an assigned nurse has a planned or emergency absence the case manager can provide a PA for the covering nurse without ending the primary nurses PA.  This allows the second nurse to bill for services she/he provides the individual.  The covering nurse can bill for a new assessment and service plan based on individual needs or their review of the other nurse’s documentation.  The nurses need to follow OSBN regulations regarding transfer and/or rescinding delegation.   The primary nurse has the responsibility under their license to notify the case manager of an absence and unless it is an emergency they must coordinate and review individual documentation with the assigned covering nurse.

Prior Authorization (PA)

​​Is a Prior Authorization needed for Reassessments? 

Yes. We ask the nurses based on their initial assessment to estimate the frequency that they might need to reassess the individual and include this on the SDS 4102.  However this is an estimate only.  Nurses cannot predict when an updated nursing assessment or reevaluation of the individual’s health status will be needed.  Sometimes this will occur during a visit scheduled for a delegation review or as a result of a call from a provider, caregiver or the case manager notifying them of a change in the individual’s condition.  Reassessment may also be needed if there is a change in the individual’s living environment or to support the delegation of a new task of nursing care. Case managers should receive as part of the Nursing Service Summary an updated Nursing Service Plan, an updated Medication Review and a copy of the nurses completed assessment if a reassessment was provided.   The nurse can use whatever format they want for this reassessment and Medication Review. 

Prior Authorization (PA)

How does the LTCCN RN know when a Prior Authorization form (SDS 4102) is authorized?

As of November 2013, local offices must send the nurse provider the automated MMIS Prior Authorization (PA) notice, to notify the LTCCN provider the PA was completed, and either approved or denied. The provider needs to maintain a copy of this notice for their records to show they received authorization to provide nursing services for the individual. The provider may also verify the PA authorization through the web portal. The signed SDS 4102 must be maintained in the individual file. Another option is for the LTCCN provider to submit the individual’s Nursing Service Plan and PA request prior to the Nursing Service Plan Review meeting, where the CM and LTCCN Provider meet to discuss the service plan and PA request form.  If the CM has time to review the plan and the PA request prior to the Nursing Service Plan Review, the nurse may obtain a signed copy of the PA at that time. 

Documentation

What type of documentation should I expect from a RN after I authorize Long Term Care RN services?

There are two required forms that the nurse completes:  The APD Long Term Care Community Nursing Service Plan (SDS 0754) and the APD Long Term Care Community Nursing Services Summary (SDS 0752).  The purpose of these forms is to ensure that the RN communicates information to you.  The documentation entered on each form is required to be legible and easily understood. The RN is not to use medical abbreviations, medical terminology or jargon. If you find that the RN is not willing to document in a manner that helps you understand their services, immediately let your manager or the LTCCN Program Coordinator know of the communication problems.  The nurse must also complete SDS 4102 as part of the authorization process. 

You should expect to receive a current Nursing Service Plan each and every time a RN makes updates to the Service Plan and when there is a request for Prior Authorized services. 

The APD Long Term Care Community Nursing Service Plan (SDS 0754) is a required form and is intended to communicate the individual’s health issue, the desired outcomes for that issue and the specific activities that the nurse will be providing for your individual to help the individual get to these outcomes, and needs to be individualized to the individual’s needs.  The LTCCN RN also uses the nursing service plan (SDS 0754) to communicate to the CM:

  • ​If delegation is needed, and the estimated service units for delegation.
  • The frequency of monitoring visits

The APD Long Term Care Community Nursing Services Summary (SDS 0752) is a required form and is to be completed by the RN for all individual encounters; i.e., a professional services visit to your individual's home, attendance at individual care team or individual support plan meetings, for any telephone consultation with the individual, the CM or another care team member concerning the individual.  The summary should address:

  • ​Individual’s current health status
  • A summary of the services provided to your individual on that date of service
  • Any proposed actions that the RN and/or you should take as a result of the services provided that day
  • Copies of reassessment and updated service plan if these activities were performed.  

Documentation

What documentation does the nurse leave at the foster home and ‘in home’ settings? 

The nurses must leave any instructions regarding teaching, delegation and reporting expectations that are needed to assure the individual’s health and safety.  Nurses must leave an entry in individual’s AFH care plan or whatever log system is set up in an individual’s ‘in-home’ setting so that it’s clear to persons working in the home when they were there and what services they provided.  Nurses who do not feel they can leave documentation at the individual’s home must communicate their concerns with the case manager and together develop an alternative plan. 

Documentation

What other documentation should a RN be providing?

As independent licensed contractors, the Long Term Care RNs have to meet documentation standards in the State Board of Nursing rules governing their nursing license; this is called ‘nursing practice’.  APD does not have the authority to define these practices.  Our forms are designed only to help the nurses summarize ‘nursing practice’ for the case managers and to provide documentation that can support their Medicaid claims.   Nurses may create additional documentation to meet their business and licensure obligations.  A RN's documentation of nursing practice is what the RN generates to meet nursing professional nursing standards and to promote the safe support of the individual in the home environment. You always have the authority to request all of the nurse’s documentation of nursing practice for your individual in the areas of individual assessment, nursing care plan, medication reviews, monitoring, care coordination, teaching and delegation.  If the RN declines to comply with your request, contact the LTCCN Program Coordinator.

Documentation

​​How long do I keep the documentation that is given to me by the Long Term Care Community RN?

The local office must retain LTCCN RN documentation for seven years. Contractors should refer to 411-048-0200 (1) (6) and their contract for requirements of documentation retention. 

Documentation

​​Can I ask a contractor to type the required forms for LTC Community Nursing? 

A contractor is not required to type the required forms, however, regardless if the forms are typed or handwritten, all of the forms and notes provided to the CM must be legible and must not contain medical or nursing, technical terms or abbreviations. If the CM doesn’t understand the RN notes, they need to contact the RN to get clarification.  If that doesn’t resolve the problem the CM should notify their manager and the manager can contact the LTCCN Program Coordinator and the coordinator will go over the program expectations with the contractor. 

Documentation

Can contractors use electronic signatures for the LTCCN required forms? 

​Yes.

Documentation

​​Is there a form for the RN Assessment? 

Since nursing assessment is part of the practice of nursing that is dictated by the State Board of Nursing we do not provide the nurses with a required form.  The Board of Nursing has detailed standards regarding what is covered and what must be documented.  RN’s can use tools of their choice to comply with this basic nursing practice but must attach for the case manager the following information: 

Identification that the document is a RN Assessment

  • Identification of to whom the Assessment was distributed and date of distribution
  • Demographics of the individual (Name, address, I.D. number, etc)
  • Summary statements in layperson language of the findings regarding the four issues noted above 
  • Name of the Long Term Care Community RN and In-Home/HH Agency if applicable
  • Date of the evaluation

This information is attached to the Nursing Service Plan.   If the nurse determines that based on the assessment that the individual does not need RN services the nurse must be paid for the time spent making this determination and the Assessment documentation can be attached to the original referral since there will be no Nursing Service Plan.  

Communication

How often should the LTCCN RN and CM communicate?

At a minimum the LTCCN RN and CM must communicate every six months before the CM authorizes the next six months of service.  The best practice is to use the information on the Nursing Service Summary (SDS 0752) as a guide for checking in with the nurse.  If the CM wants more information on an event the CM should contact the nurse. Guidelines for communication include:

  • Both the case manager and the nurse will contact each other in a timely manner whenever they become aware of a change of condition (see the referral list) or the individual needs more intensive medical supports such as hospitalization, a referral to specialist or a change in physician services.
  • Frequent communication by email is encouraged as the case manager can easily add these information to the ACCESS narrative
  • Scheduling of face to face meetings must factor in the case manager’s workload, schedule and the fact that nurses do not get paid for travel time.
  • Problems or concerns that either the nurse or case manager has regarding communication must be immediately brought to management attention.  

Communication

Do I need secure email to communicate with the CM? 

The LTCCN Provider must provide all written, and electronic information regarding individuals to comply with HIPAA, and must use a secure email system, refer to OAR 411-048-0190(2).  

Communication

What if the LTCCN RN needs an interpreter to provide nursing services?


If the nurse needs an interpreter to provide nursing services such as teaching or delegation for the individual or caregivers, the nurse should contact the CM to arrange interpreter services; the nurse should not arrange for interpreter services without contacting the CM.  

Communication

What if the RN stops communicating with me or stops providing me with documentation concerning my individual?

If a LTCCN RN stops communicating with you or stops providing you with documentation at the visitation frequency identified on the Nursing Service Plan, contact the RN directly and ask why there has been no documentation or communication concerning your individual. Long Term Care RNs are required to submit a completed RN Services Summary to you for every individual encounter. If you cannot reach the LTCCN RN alert local management. 

Communication

​​How does the RN know if an individual has been moved to another service location or is no longer eligible?

Nurses always need to check the MMIS web portal before providing services to verify that the person is eligible.  Case managers and LTCCN RNs are expected to communication to each other if either of them become aware of changes in an individual’s health conditions that would impact the nursing service plan.

Communication

​​Can the LTCCN RN and Case Manager review service plans over the phone? 

Face to face meetings are optimal for the six month Nursing Service Plan reviews of nursing service plans especially if either the individual or the nurse is new to the case manager, however the LTCCN RN and CM may mutually agree to conduct the review by phone.   A face to face meeting ensures that you and the nurse have a common understanding of the individual’s needs and how the nurse plans to meet these needs.  It is easier to ask the nurse for clarification or additional information if the meeting is face to face. 

Hospice and Home Health Services

​​Can an individual receive Home Health or Hospice nursing and LTC Community Nursing? 

When an individual’s condition deteriorates to an unstable, fluctuating or unpredictable status and will require nursing from home health, hospice or an In-Home agency the case manager should be informed. An assigned LTCCN RN might continue to provide the supports in the individual’s LTCCN nursing service plan during a period of deterioration while the person is also receiving different short term nursing services for the acute condition. In these situations the two RNs are expected to coordinate the services they provide to ensure there is no duplication of nursing services.  Coordination might include sharing their service plans and establishing points of communication such as notification when the short term nursing service ends.

Hospice and Home Health Services

What if my individual who has RN services goes on Hospice?

When an individual who is receiving RN services goes on Hospice, you as a case manager must determine if the Hospice program will be providing all nursing services for the individual including any teaching or delegation that the individual or his/her caregivers will need.  If the Hospice program is providing an ongoing nurse to the individual’s case then the APD funded RN services must end.  Hospice is funded to provide a full range of nursing supports; including assessment and planning, directions for seeking medical care, delegation and training for care providers, coordination for equipment needs, review of medications and other orders, pain management and comfort measures, anxiety management and direct services. If an individual stabilizes and Hospice services are stopped, then you may need to restart the RN service.   Contact your local manager if you have an unusual situation where you think both nursing services may be needed.

In-Home and Home Health Agencies and Long Term Care Community Nursing

​​Can an In-Home individual who receives services from a contracted In-Home Agency also receive LTC Nursing Services?

LTCCN RNs can be assigned to in-home individuals only if the individual has a Home Care Worker(s)(HCW) providing services in addition to the  employees of the In Home Agency and the HCW has to perform a delegated task.  The LTCCN RN would not provide delegation to employees of the In Home Agency, and would only provide delegation to the HCW(s).  In these situations the LTCCN RN would be expected to use Care Coordination time to coordinate teaching, delegation instructions and nursing service plans with the nursing services the Agency is providing, and document that coordination.  If an In Home Agency refuses to provide nursing services including delegation for their employees for any individuals they have accepted for In Home agency services then the person’s case manager and the In-Home Agency Program Coordinator need to be notified. 

In-Home and Home Health Agencies and Long Term Care Community Nursing

​​Can a contracted In-Home Agency provide delegation or teaching for CEP/HCW providers if the In-Home individual they are serving has both agency staff and CEP/HCW providers?

At this time, an In Home agency that provides In Home agency services to individuals cannot provide LTCCN RN services for any individuals they serve, even if those same individuals have CEPs/HCWs. 

Long Term Care Community Nursing Services Reimbursement

How do I get paid for Long Term Care Community Nursing? 

The procedure codes and services are described in the LTCCN Procedure Codes & Payment Authorization Guidelines and the claims process is described in a training video (add link).  Except for the Initial Assessment, these services are paid in units and are not bundled because the range of individual acuity and needs in the approximately 3000 persons served each year are very diverse and an accurate bundled rate cannot be determined. 

Long Term Care Community Nursing Services Reimbursement

​​What is the MMIS payment system? 

This is a federally required system to process all Medicaid payments.  Any questions, problems or suggestions on how to improve this system should be directed to Provider Services.

Additional Resource information

Where can I find more information for the LTCCN Program? 

The program’s website is located at http://www.oregon.gov/dhs/spwpd/apd-providers/ltc-community-nurses/Pages/index.aspx  Users will find program information, rules, policies, required forms, tools and resources, how to become a provider, and contact information on the website.  Interested persons may subscribe to the page and will be informed by an email notice when information is added to the site. Contractors are responsible to check the site regularly for updates as part of their contract.  

 

Additional Resource information

​​What if I know of a RN who is interested in participating in the Long Term Care Community Nursing Program?

When you become aware of a RN who is interested in participating in the Long Term Care Community Nursing Program, refer them to the APD Provider Long Term Care Community Nursing website: ”Becoming A Provider.”  Information is available about the program or direct them to the Manager in your office responsible for Long Term Care Community Nursing service.

Additional Resource information

​​Who do I contact if I have a complaint about a RN or if I receive a complaint concerning a RN from an individual, a foster home provider or an In-Home worker?

 

All complaints and concerns regarding LTCCN RNs must be communicated to the LTCCN Program Coordinator.  Situations requiring an immediate call to Salem include:  

 

  • When a RN becomes the subject of a protective services investigation;
  • When a protective service investigation substantiates abuse or neglect on the part of the nurse;
  • When a professional practice complaint will be made/reported to the Oregon State Board of Nursing (OSBN) about the LTCCN RN's actions
  • If your are wondering if you should refer a RN to either OSBN or protective service;
  • Any concerns about the quality or quantity of  RN services being delivered to an individual;
  • A professional boundary breach or violation  https://www.ncsbn.orq/Professional Boundaries 2007 Web.pdf
  • Failure of the RN to provide the services that have been prior authorized and required for an individual.
  • You have heard that the RN has been charged with a misdemeanor or felony. 

 

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