Services requiring prior authorization that are provided without prior authorization;
Supervision of the recipient when supervision is the only service provided at the time;
Medications administration by a personal care worker or administration by a home health aide which has not been delegated by an RN according to the relevant provisions of ch. DHS 133
Skilled nursing services contracted for by a home health agency unless the requirements of s. DHS 133.19
are met and approved by the department;
Occupational therapy, physical therapy or speech pathology services requiring only the use of equipment without the skills of the therapist or speech pathologist;
Solely for the purpose of ensuring that a recipient who has a demonstrated history of noncompliance over 30 days complies with the medications program;
To administer or assist with medication administration of an adult recipient who is capable of safely self-administering a medication as determined and documented by the RN;
To inject a recipient who is capable of safely self-injecting a medication, as described and documented by the RN;
To prefill syringes for self-injection when, as determined and documented by the RN, the recipient is capable of prefilling or a pharmacy is available to prefill; and
To set up medication for self-administration when, as determined and documented by the RN, the recipient is capable or a pharmacy is available to assist the recipient;
Home health services to a recipient who is eligible for covered services under the medicare program or any other insurance held by the recipient;
Services that are not medically appropriate. In this paragraph,“medically appropriate" means a service that is proven and effective treatment for the condition for which it is intended or used;
A visit made by a skilled nurse, physical or occupational therapist or speech pathologist solely to train other home health workers;
Any home health service included in the daily rate of the community-based residential facility where the recipient is residing;
Services when provided to a recipient by the recipient's spouse or parent if the recipient is under age 18;
Skilled nursing and therapy services provided to a recipient who is not confined to a place of residence when services are reasonably available outside the residence;
Any service which is performed in a place other than the recipient's residence; and
In this subsection, “part-time, intermittent care" means skilled nursing services provided in a recipient's home under a plan of care which requires less than 8 hours of skilled care in a calendar day.
Part-time, intermittent nursing care may be provided by an independent nurse certified under s. DHS 105.19
when an existing home health agency cannot provide the services as appropriately documented by the nurse, and the physician's prescription specifies that the recipient requires less than 8 hours of skilled nursing care per calendar day and calls for a level of care which the nurse is licensed to provide as documented to the department.
Services provided by an MA-certified registered nurse are those services prescribed by a physician which comprise the practice of professional nursing as described under s. 441.001 (4)
, Stats., and s. N 6.03
. Services provided by an MA-certified licensed practical nurse are those services which comprise the practice of practical nursing under s. 441.001 (3)
, Stats., and s. N 6.04
. An LPN may provide nursing services delegated by an RN as delegated nursing acts under the requirements of ss. N 6.03
and guidelines established by the state board of nursing.
A written plan of care shall be established for every recipient admitted for care and shall be signed by the physician and incorporated into the recipient's medical record. A written plan of care shall be developed by the registered nurse or therapist within 72 hours after acceptance. The written plan of care shall be developed by the registered nurse or therapist in consultation with the recipient and the recipient's physician and shall be signed by the physician within 20 working days following the recipient's admission for care. The written plan of care shall include, in addition to the medication and treatment orders:
Methods for delivering needed care, and an indication of which, if any, professional disciplines are responsible for delivering the care;
Provision for care coordination by an RN when more than one nurse is necessary to staff the recipient's case;
Identification of all other parties providing care to the recipient and the responsibilities of each party for that care; and
A description of functional capabilities, mental status, dietary needs and allergies.
The written plan of care shall be reviewed, signed and dated by the recipient's physician as often as required by the recipient's condition but at least every 62 days. The RN shall promptly notify the physician of any change in the recipient's condition that suggests a need to modify the plan of care.
Except as provided in subd. 5. b.
, drugs and treatment shall be administered by the RN or LPN only as ordered by the recipient's physician or his or her designee. The nurse shall immediately record and sign oral orders and shall obtain the physician's countersignature within 10 working days.
Supervision of an LPN by an RN or physician shall be performed according to the requirements under ss. N 6.03
and the results of supervisory activities shall be documented and communicated to the LPN.
Prior authorization requirements under sub. (3)
apply to services provided by an independent nurse.
A request for prior authorization of part-time, intermittent care performed by an LPN shall include the name and license number of the registered nurse supervising the LPN.
Each independent RN or LPN shall document the care and services provided. Documentation required under par. (b)
of the unavailability of a home health agency shall include names of agencies contacted, dates of contact and any other pertinent information.
Registered nurse supervision of an LPN is not separately reimbursable.
(e) Non-covered services.
The following services are not covered services under this subsection:
Any service that fails to meet the recipient's medical needs or places the recipient at risk for a negative treatment outcome.
DHS 107.11 History
Cr. Register, February, 1986, No. 362
, eff. 3-1-86; r. and recr. Register, April, 1988, No. 388
, eff. 7-1-88; am. (3) (d) and (e), cr. (3) (f), Register, December, 1988, No. 396
, eff. 1-1-89; emerg. r. and recr. eff. 7-1-92; r. and recr. Register, February, 1993, No. 446
, eff. 3-1-93; emerg. cr. (3) (ag), eff. 1-1-94; correction in (6) (b) 1. made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520
; corrections in (1) (c), (2) (b) 1. and (5) (i) and (j) made under s. 13.93 (2m) (b) 7., Stats., Register, October, 2000, No. 538
; correction in (4) (k) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554
; CR 03-033
: am. (6) (b) 5. Register December 2003 No. 576
, eff. 1-1-04; corrections in (6) (b) 2. made under s. 13.93 (2m) (b) 7., Stats., Register December 2003 No. 576
; corrections in (1) (c), (2) (intro.), (b) 1., (4) (c), (k), (5) (i), (j) and (6) (d) 2. made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636
Personal care services are medically oriented activities related to assisting a recipient with activities of daily living necessary to maintain the recipient in his or her place of residence in the community. These services shall be provided upon written orders of a physician by a provider certified under s. DHS 105.17
and by a personal care worker employed by the provider or under contract to the provider who is supervised by a registered nurse according to a written plan of care. The personal care worker shall be assigned by the supervising registered nurse to specific recipients to do specific tasks for those recipients for which the personal care worker has been trained. The personal care worker's training for these specific tasks shall be assured by the supervising registered nurse. The personal care worker is limited to performing only those tasks and services as assigned for each recipient and for which he or she has been specifically trained.
Assistance with mobility and ambulation including use of walker, cane or crutches;
Changing the recipient's bed and laundering the bed linens and the recipient's personal clothing;
Light cleaning in essential areas of the home used during personal care service activities;
Prior authorization is required for personal care services in excess of 250 hours per calendar year.
The personal care worker is trained and supervised by the provider to provide the tasks; and
The recipient, parent or responsible person is permitted to participate in the training and supervision of the personal care worker.
Personal care services shall be performed under the supervision of a registered nurse by a personal care worker who meets the requirements of s. DHS 105.17 (3)
and who is employed by or is under contract to a provider certified under s. DHS 105.17
Services shall be performed according to a written plan of care for the recipient developed by a registered nurse for purposes of providing necessary and appropriate services, allowing appropriate assignment of a personal care worker and setting standards for personal care activities, giving full consideration to the recipient's preferences for service arrangements and choice of personal care workers. The plan shall be based on the registered nurse's visit to the recipient's home and shall include:
Assessment of the recipient's social and physical environment, including family involvement, living conditions, the recipient's level of functioning and any pertinent cultural factors such as language.
Review of the plan of care, evaluation of the recipient's condition and supervisory review of the personal care worker shall be made by a registered nurse at least every 60 days. The review shall include a visit to the recipient's home, review of the personal care worker's daily written record and discussion with the physician of any necessary changes in the plan of care.
Reimbursement for registered nurse supervisory visits is limited to one visit per month.
No more than one-third of the time spent by a personal care worker may be in performing housekeeping activities.
(4) Non-covered services.
The following services are not covered services:
Personal care services provided in a hospital or a nursing home or in a community-based residential facility, as defined in s. 50.01 (1)
, Stats., with more than 20 beds;
Homemaking services and cleaning of areas not used during personal care service activities, unless directly related to the care of the person and essential to the recipient's health;