DHS 107.09(4)(e)3.3. A service that is ordinarily nonskilled shall be considered a skilled service where, because of medical complications, its performance or supervision or the observation of the patient necessitates the use of skilled nursing or skilled rehabilitation personnel. For example, the existence of a plaster cast on an extremity generally does not indicate a need for skilled care, but a patient with a preexisting acute skin problem or with a need for special traction of the injured extremity might need to have technical or professional personnel properly adjust traction or observe the patient for complications. In these cases, the complications and special services involved shall be documented by physician’s orders and nursing or therapy notes. DHS 107.09(4)(f)(f) Skilled nursing services or skilled rehabilitation services. DHS 107.09(4)(f)1.1. A nursing home shall provide either skilled nursing services or skilled rehabilitation services on a 7-day-a-week basis. If, however, skilled rehabilitation services are not available on a 7-day-a-week basis, the nursing home would meet the requirement in the case of a patient whose inpatient stay is based solely on the need for skilled rehabilitation services if the patient needs and receives these services on at least 5 days a week. DHS 107.09 NoteNote: For example, where a facility provides physical therapy on only 5 days a week and the patient in the facility requires and receives physical therapy on each of the days on which it is available, the requirement that skilled rehabilitation services be provided on a daily basis would be met.
DHS 107.09(4)(f)2.2. Examples of services which could qualify as either skilled nursing or skilled rehabilitation services are: DHS 107.09(4)(f)2.a.a. Overall management and evaluation of the care plan. The development, management and evaluation of a patient care plan based on the physician’s orders constitute skilled services when, in terms of the patient’s physical or mental condition, the development, management and evaluation necessitate the involvement of technical or professional personnel to meet needs, promote recovery and actuate medical safety. This includes the management of a plan involving only a variety of personal care services where in light of the patient’s condition the aggregate of the services necessitates the involvement of technical or professional personnel. Skilled planning and management activities are not always specifically identified in the patient’s clinical record. In light of this, where the patient’s overall condition supports a finding that recovery or safety can be assured only if the total care required is planned, managed, and evaluated by technical or professional personnel, it is appropriate to infer that skilled services are being provided; DHS 107.09(4)(f)2.b.b. Observation and assessment of the patient’s changing condition. When the patient’s condition is such that the skills of a nurse or other technical or professional person are required to identify and evaluate the patient’s need for possible modification of treatment and the initiation of additional medical procedures until the patient’s condition is stabilized, the services constitute skilled nursing or rehabilitation services. Patients who in addition to their physical problems exhibit acute psychological symptoms such as depression, anxiety or agitation may also require skilled observation and assessment by technical or professional personnel for their safety and the safety of others. In these cases, the special services required shall be documented by a physician’s orders or nursing or therapy notes; and DHS 107.09(4)(f)2.c.c. Patient education. In cases where the use of technical or professional personnel is necessary to teach a patient self-maintenance, the teaching services constitute skilled nursing or rehabilitative services. DHS 107.09(4)(g)1.a.a. Considered appropriate by the department and provided by a Christian Science sanatorium either operated by or listed and certified by the First Church of Christ Scientist, Boston, Mass.; or DHS 107.09(4)(g)1.b.b. Provided by a facility located on an Indian reservation that furnishes, on a regular basis, health-related services and is licensed pursuant to s. 50.03, Stats., and ch. DHS 132. DHS 107.09(4)(g)2.2. Intermediate care services may include services provided in an institution for developmentally disabled persons if: DHS 107.09(4)(g)2.a.a. The primary purpose of the institution is to provide health or rehabilitation services for developmentally disabled persons; DHS 107.09(4)(g)3.3. Intermediate care services may include services provided in a distinct part of a facility other than an intermediate care facility if the distinct part: DHS 107.09(4)(g)3.b.b. Is an identifiable unit, such as an entire ward or contiguous ward, a wing, a floor, or a building; DHS 107.09(4)(g)3.d.d. Houses all recipients for whom payment is being made for intermediate care facility services, except as provided in subd. 4.; DHS 107.09(4)(g)4.4. If the department includes as intermediate care facility services those services provided by a distinct part of a facility other than an intermediate care facility, it may not require transfer of a recipient within or between facilities if, in the opinion of the attending physician, transfer might be harmful to the physical or mental health of the recipient. DHS 107.09(4)(h)(h) Determining the appropriateness of services at the skilled level of care. DHS 107.09(4)(h)1.1. In determining whether the services needed by a recipient can only be provided in a skilled nursing facility on an inpatient basis, consideration shall be given to the patient’s condition and to the availability and feasibility of using more economical alternative facilities and services. DHS 107.09(4)(h)2.2. If a needed service is not available in the area in which the individual resides and transporting the person to the closest facility furnishing the services would be an excessive physical hardship, the needed service may be provided in a skilled nursing facility. This would be true even though the patient’s condition might not be adversely affected if it would be more economical or more efficient to provide the covered services in the institutional setting. DHS 107.09(4)(h)3.3. In determining the availability of alternative facilities and services, the availability of funds to pay for the services furnished by these alternative facilities shall not be a factor. For instance, an individual in need of daily physical therapy might be able to receive the needed services from an independent physical therapy practitioner.