Florida Regulations 59G-4.180: Intermediate Care Services
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(1) Purpose. This rule establishes the level of care criteria that must be met in order for nursing and rehabilitation services to qualify as intermediate care services and clarifies the criteria that must be met in order for such services to qualify as an intermediate level I or intermediate level II service under Medicaid.
(2) Definitions as used in this section.
(a) Intermediate care nursing home resident. A Medicaid nursing home applicant or recipient who requires intermediate care services including 24-hour observation and care and the constant availability of medical and nursing treatment and care, but not to the degree of care and treatment provided in a hospital or that which meets the criteria for skilled nursing services.
(b) Rehabilitation services. Individualized activities or exercises prescribed by health care professionals that are designed to restore the recipient to self-sufficiency or to maintain the recipient at the highest attainable functional level.
(c) Routine. The administration of medications, treatments, or services in accordance with an established or predetermined schedule and performed for individuals whose medical needs are stabilized or chronic.
(3) Intermediate Services criteria.
(a) To be classified as requiring Intermediate Care Services, Level I or Level II in the community or in a nursing facility, the applicant or recipient must require the type of medical, nursing or rehabilitation services specified in this subsection.
(b) Intermediate Care Services. To be classified as intermediate care services, the nursing or rehabilitation service must be:
1. Ordered by and remain under the supervision of a physician;
2. Medically necessary and provided to an applicant or recipient whose health status and medical needs are of sufficient seriousness as to require nursing management, periodic assessment, planning or intervention by licensed nursing or other health professionals;
3. Required to be performed under the supervision of licensed nursing or other health professionals;
4. Necessary to achieve the medically desired results and to ensure the comfort and safety of the applicant or recipient;
5. Required on a daily or intermittent basis;
6. Reasonable and necessary to the treatment of a specific documented medical disorder, disease or impairment; and,
7. Consistent with the nature and severity of the individual’s condition or the disease state or stage.
(c) When determining whether intermediate care services are required, consideration shall be given to the nature of the services prescribed and to which level of nursing or other health care personnel meets the qualifications necessary to provide such services, the availability and accessibility of community or alternative resources, and how the recipient’s, applicant’s or resident’s needs can be most effectively and efficiently met.
(d) The amount of care required shall not be a primary factor in determining whether or not an applicant or resident requires intermediate care services.
(e) To qualify for placement in a nursing facility, the applicant or recipient must require intermediate care services including 24 hour observation and care and the constant availability of medical and nursing treatment and care, but not to the degree of care and services provided in a hospital or that meets the criteria for skilled services.
(4) Intermediate Care Services Level I.
(a) Intermediate Care Service Level I is extensive health related care and service required by an individual who is incapacitated mentally or physically.
(b) Examples of services that qualify as Intermediate Care Services Level I:
1. Administration of routine or stabilized dosages of oral medication, eye drops or ointments;
2. Routine administration of intramuscular or subcutaneous medication and observation of the individual’s response and side effects;
3. Administration and adjustment of medication for pain and the monitoring of results and side effects;
4. Routine administration of insulin to a diabetic resident whose condition is stable, but who is unable to self-administer due to physical, mental or medical reasons;
5. Routine oral suctioning;
6. Tracheostomy care when the individual’s condition is stable, but the individual is unable to care for the tracheostomy due to physical, mental or medical reasons;
7. Routine intermittent positive pressure breathing (IPPB) therapy after a regimen of therapy has been established or therapy is performed by the resident with nursing supervision;
8. Routine care of stoma and surrounding skin in the presence of colostomy, gastrostomy or ileostomy, excluding the initial period of training, teaching or intensive care, and special problems, for example, bleeding, severe diarrhea, or stricture;
9. Routine care of a supra-pubic catheter, excluding special care in cases of hemorrhage, frequent obstruction, frequent changes;
10. Routine services to maintain satisfactory functioning of indwelling bladder catheters, including routine insertion of catheter and, excluding special care in cases of infection, hemorrhage, frequent obstruction, frequent changes of the catheter, irrigations more than two times daily, or the use of special medications for irrigation and instillation;
11. Changes of dressings, sterile or aseptic, for noninfected postoperative or chronic conditions;
12. Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor and noninfected skin problems;
13. Routine care of the incontinent resident, including the use of diapers and protective sheets;
14. General maintenance care in connection with a plaster cast;
15. Routine care in connection with temporary casts, splints, braces or similar devices, excluding observing for circulatory or skin changes in unstable cases;
16. Decubitus care involving superficial, noninfected lesions and preventive measures when a resident is susceptible to decubitic formation;
17. Bowel and bladder control training and maintenance after a successful program has been established;
18. Care of a resident with an amputation or a fracture requiring routine care of a stabilized condition and reinforcement of an established rehabilitation plan;
19. Use of heat as a palliative and comfort measure, such as whirlpool and hydrocollator, including the use of special baths with whirl-type action when not required to be performed by a physical therapist or licensed nurse;
20. Routine administration of medical gases after a regimen of therapy has been established by a physician and is administered by the resident;
21. Assistance or supervision in dressing, eating and toileting;
22. Periodic positioning or repositioning;
23. General supervision of exercises which have been taught to the resident, including the carrying out of a maintenance program, for example, the performance of repetitive exercises required to maintain functions in paralyzed extremities, assisted walking, and similar procedures;
24. Administration of oxygen on an emergency or short-term basis;
25. Rehabilitative restorative care, passive range of motion (ROM) exercise;
26. Routine use of physical restraints or protective devices; and,
27. Routine dietary management.
(c) Intermediate Care Services Level II is limited health related care and services required by an individual who is mildly incapacitated or ill to a degree to require medical supervision. Individuals requiring this level of care shall:
1. Be ambulatory, with or without assistive devices,
2. Demonstrate independence in activities of daily living, and,
3. Not require the administration of psychotropic drugs on a daily or intermittent basis or exhibit periods of disruptive or disorganized behavior requiring 24-hour nursing supervision.
(d) Examples of services, in addition to medical supervision, that qualify as intermediate care Level II:
1. Administration of routine oral medication;
2. Assistance with mobilization, helping a resident maintain balance when transferring from bed to chair and providing necessary help when climbing steps or manipulating wheelchair in difficult places;
3. Assistance with bathing, that is, assembling towels, soap, and other necessary supplies, helping the recipient in and out of the bathtub or shower, turning the water on and off, adjusting water temperature, washing and drying portions of the body which are difficult for the recipient to reach and being available while the recipient is bathing himself;
4. Assistance with dressing, that is, helping the recipient to choose and to put on appropriate clean clothing, and fastening hooks, buttons, zippers and ties;
5. Assistance with meals, that is, helping with cutting up food and pouring beverages;
6. Assistance with grooming, that is, helping the recipient to shave, wash, comb and curl hair, and to clean and file fingernails and toenails. Fingernails or toenails should not be cut by the recipient unless approved by the physician;
7. Provision of social and leisure services which are arranged for and individually designed to reduce isolation and withdrawal and to enhance communication and social skills;
8. Self-administration of medical gases, oral medications, subcutaneous medication after a regimen of therapy has been established and self-administration approved by the physician;
9. Ongoing medical and social evaluations to determine the point when a recipient’s progress has reached the stage at which medical and related needs can be met appropriately outside of the nursing facility or through alternative placement or services;
10. Application of dressings and treatments prescribed by the physician for small or superficial areas requiring a dressing;
11. Application of elastic stockings, when prescribed, if the recipient cannot manage independently;
12. Administration of oxygen or intermittent positive pressure breathing when prescribed by the physician and performed by the recipient;
13. Assistance with colostomy care, that is, helping the recipient care for permanent colostomy which the recipient ordinarily cares for;
14. Routine measurement and recording of vital signs and weights, including being alert to symptoms and readings corresponding to abnormal conditions of the residents;
15. Routine restorative and rehabilitation procedures, that is, the encouragement and incorporation of range of motion exercises in the daily activities schedule.
Rulemaking Authority 409.919 FS. Law Implemented 409.905(2), (4), (8), 409.906(14) FS. History-New 1-1-77, Formerly 10C-7.33, Amended 12-2-86, Formerly 10C-7.033, Amended 2-28-95.
(a) Intermediate care nursing home resident. A Medicaid nursing home applicant or recipient who requires intermediate care services including 24-hour observation and care and the constant availability of medical and nursing treatment and care, but not to the degree of care and treatment provided in a hospital or that which meets the criteria for skilled nursing services.
(b) Rehabilitation services. Individualized activities or exercises prescribed by health care professionals that are designed to restore the recipient to self-sufficiency or to maintain the recipient at the highest attainable functional level.
(c) Routine. The administration of medications, treatments, or services in accordance with an established or predetermined schedule and performed for individuals whose medical needs are stabilized or chronic.
(3) Intermediate Services criteria.
(a) To be classified as requiring Intermediate Care Services, Level I or Level II in the community or in a nursing facility, the applicant or recipient must require the type of medical, nursing or rehabilitation services specified in this subsection.
(b) Intermediate Care Services. To be classified as intermediate care services, the nursing or rehabilitation service must be:
1. Ordered by and remain under the supervision of a physician;
2. Medically necessary and provided to an applicant or recipient whose health status and medical needs are of sufficient seriousness as to require nursing management, periodic assessment, planning or intervention by licensed nursing or other health professionals;
3. Required to be performed under the supervision of licensed nursing or other health professionals;
4. Necessary to achieve the medically desired results and to ensure the comfort and safety of the applicant or recipient;
5. Required on a daily or intermittent basis;
6. Reasonable and necessary to the treatment of a specific documented medical disorder, disease or impairment; and,
7. Consistent with the nature and severity of the individual’s condition or the disease state or stage.
(c) When determining whether intermediate care services are required, consideration shall be given to the nature of the services prescribed and to which level of nursing or other health care personnel meets the qualifications necessary to provide such services, the availability and accessibility of community or alternative resources, and how the recipient’s, applicant’s or resident’s needs can be most effectively and efficiently met.
(d) The amount of care required shall not be a primary factor in determining whether or not an applicant or resident requires intermediate care services.
(e) To qualify for placement in a nursing facility, the applicant or recipient must require intermediate care services including 24 hour observation and care and the constant availability of medical and nursing treatment and care, but not to the degree of care and services provided in a hospital or that meets the criteria for skilled services.
(4) Intermediate Care Services Level I.
(a) Intermediate Care Service Level I is extensive health related care and service required by an individual who is incapacitated mentally or physically.
(b) Examples of services that qualify as Intermediate Care Services Level I:
1. Administration of routine or stabilized dosages of oral medication, eye drops or ointments;
2. Routine administration of intramuscular or subcutaneous medication and observation of the individual’s response and side effects;
3. Administration and adjustment of medication for pain and the monitoring of results and side effects;
4. Routine administration of insulin to a diabetic resident whose condition is stable, but who is unable to self-administer due to physical, mental or medical reasons;
5. Routine oral suctioning;
6. Tracheostomy care when the individual’s condition is stable, but the individual is unable to care for the tracheostomy due to physical, mental or medical reasons;
7. Routine intermittent positive pressure breathing (IPPB) therapy after a regimen of therapy has been established or therapy is performed by the resident with nursing supervision;
8. Routine care of stoma and surrounding skin in the presence of colostomy, gastrostomy or ileostomy, excluding the initial period of training, teaching or intensive care, and special problems, for example, bleeding, severe diarrhea, or stricture;
9. Routine care of a supra-pubic catheter, excluding special care in cases of hemorrhage, frequent obstruction, frequent changes;
10. Routine services to maintain satisfactory functioning of indwelling bladder catheters, including routine insertion of catheter and, excluding special care in cases of infection, hemorrhage, frequent obstruction, frequent changes of the catheter, irrigations more than two times daily, or the use of special medications for irrigation and instillation;
11. Changes of dressings, sterile or aseptic, for noninfected postoperative or chronic conditions;
12. Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor and noninfected skin problems;
13. Routine care of the incontinent resident, including the use of diapers and protective sheets;
14. General maintenance care in connection with a plaster cast;
15. Routine care in connection with temporary casts, splints, braces or similar devices, excluding observing for circulatory or skin changes in unstable cases;
16. Decubitus care involving superficial, noninfected lesions and preventive measures when a resident is susceptible to decubitic formation;
17. Bowel and bladder control training and maintenance after a successful program has been established;
18. Care of a resident with an amputation or a fracture requiring routine care of a stabilized condition and reinforcement of an established rehabilitation plan;
19. Use of heat as a palliative and comfort measure, such as whirlpool and hydrocollator, including the use of special baths with whirl-type action when not required to be performed by a physical therapist or licensed nurse;
20. Routine administration of medical gases after a regimen of therapy has been established by a physician and is administered by the resident;
21. Assistance or supervision in dressing, eating and toileting;
22. Periodic positioning or repositioning;
23. General supervision of exercises which have been taught to the resident, including the carrying out of a maintenance program, for example, the performance of repetitive exercises required to maintain functions in paralyzed extremities, assisted walking, and similar procedures;
24. Administration of oxygen on an emergency or short-term basis;
25. Rehabilitative restorative care, passive range of motion (ROM) exercise;
26. Routine use of physical restraints or protective devices; and,
27. Routine dietary management.
(c) Intermediate Care Services Level II is limited health related care and services required by an individual who is mildly incapacitated or ill to a degree to require medical supervision. Individuals requiring this level of care shall:
1. Be ambulatory, with or without assistive devices,
2. Demonstrate independence in activities of daily living, and,
3. Not require the administration of psychotropic drugs on a daily or intermittent basis or exhibit periods of disruptive or disorganized behavior requiring 24-hour nursing supervision.
(d) Examples of services, in addition to medical supervision, that qualify as intermediate care Level II:
1. Administration of routine oral medication;
2. Assistance with mobilization, helping a resident maintain balance when transferring from bed to chair and providing necessary help when climbing steps or manipulating wheelchair in difficult places;
3. Assistance with bathing, that is, assembling towels, soap, and other necessary supplies, helping the recipient in and out of the bathtub or shower, turning the water on and off, adjusting water temperature, washing and drying portions of the body which are difficult for the recipient to reach and being available while the recipient is bathing himself;
4. Assistance with dressing, that is, helping the recipient to choose and to put on appropriate clean clothing, and fastening hooks, buttons, zippers and ties;
5. Assistance with meals, that is, helping with cutting up food and pouring beverages;
6. Assistance with grooming, that is, helping the recipient to shave, wash, comb and curl hair, and to clean and file fingernails and toenails. Fingernails or toenails should not be cut by the recipient unless approved by the physician;
7. Provision of social and leisure services which are arranged for and individually designed to reduce isolation and withdrawal and to enhance communication and social skills;
8. Self-administration of medical gases, oral medications, subcutaneous medication after a regimen of therapy has been established and self-administration approved by the physician;
9. Ongoing medical and social evaluations to determine the point when a recipient’s progress has reached the stage at which medical and related needs can be met appropriately outside of the nursing facility or through alternative placement or services;
10. Application of dressings and treatments prescribed by the physician for small or superficial areas requiring a dressing;
11. Application of elastic stockings, when prescribed, if the recipient cannot manage independently;
12. Administration of oxygen or intermittent positive pressure breathing when prescribed by the physician and performed by the recipient;
13. Assistance with colostomy care, that is, helping the recipient care for permanent colostomy which the recipient ordinarily cares for;
14. Routine measurement and recording of vital signs and weights, including being alert to symptoms and readings corresponding to abnormal conditions of the residents;
15. Routine restorative and rehabilitation procedures, that is, the encouragement and incorporation of range of motion exercises in the daily activities schedule.
Rulemaking Authority 409.919 FS. Law Implemented 409.905(2), (4), (8), 409.906(14) FS. History-New 1-1-77, Formerly 10C-7.33, Amended 12-2-86, Formerly 10C-7.033, Amended 2-28-95.