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.

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.
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).  

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.  

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. 

​​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.


​​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. 

​​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.

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.    

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.  

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. 

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.

​​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. 

​​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. 

Can contractors use electronic signatures for the LTCCN required forms? 


​​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.  

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.

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. 

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. 

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. 

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.

​​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.

Hospice/Home Health
​​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/Home Health
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.

IHCA/Home Health
​​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. 

IHCA/Home Health
​​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. 

IHCA/Home Health
​​What is the geographic area that an In-Home Care agency or Home Health agency can provide LTC Nursing Services?

The Long Term Care (LTC) Community Nursing has contracted with several In-Home Care Agency (IHCA) and Home Health (HH) agencies to provide LTC Community Nursing Services subject to the standards in OAR 411-048-0210.

IHCA and HH agencies are licensed by OHA, Public Health, Health Care Regulation and Quality Improvement (HCRQI), and licensing standards do not allow IHCA or HH agencies to provide nursing services more than 60 miles from the agency’s “parent” agency office.

It is the responsibility of the IHCA/HH agency to screen a client referral and ensure the location of the referral meets their licensing requirements.

If a IHCA/HH agency contracted to provide LTC Community Nursing Services is interested in a possible mileage waiver, the agency should be referred to APD’s LTC Community Nursing Program Coordinator, to coordinate with the OHA, Health Care Regulation and Quality Improvement Program​

IHCA/Home Health

​​Can a Home Health agency providing LTCCN services to a client provide Home Health nursing for that same client? 

Yes. The Home Health RN and the RN providing LTC Community Nursing Services must coordinate and clearly document the services they are providing to ensure there is no duplication of nursing services.   

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.
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.

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.  

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