CMS Pub. 100-02, ch. 8, § 30.2.3.1

A3-3132.1.C.1, SNF-214.1.C.1

The development, management, and evaluation of a patient care plan, based on the

physician’s orders and supporting documentation, constitute skilled nursing services

when, in terms of the patient’s physical or mental condition, these services require the

involvement of skilled nursing personnel to meet the patient’s medical needs, promote

recovery, and ensure medical safety. However, the planning and management of a

treatment plan that does not involve the furnishing of skilled services may not require

skilled nursing personnel; e.g., a care plan for a patient with organic brain syndrome who

requires only oral medication and a protective environment. The sum total of nonskilled

services would only add up to the need for skilled management and evaluation when the

condition of the beneficiary is such that there is an expectation that a change in condition

is likely without that intervention.

The patient’s clinical record may not always specifically identify “skilled planning and

management activities” as such. Therefore, in this limited context, if the documentation

of the patient’s overall condition substantiates a finding that the patient’s medical needs

and safety can be addressed only if the total care, skilled or not, is planned and managed

by skilled nursing personnel, it is appropriate to infer that skilled management is being

provided, but only if the record as a whole clearly establishes that there was a likely

potential for serious complications without skilled management, as illustrated in the

following Examples.

EXAMPLE 1:

An aged patient with a history of diabetes mellitus and angina pectoris is recovering from

an open reduction of the neck of the femur. He requires, among other services, careful

skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise program to

preserve muscle tone and body condition, and observation to notice signs of deterioration

in his condition or complications resulting from his restricted (but increasing) mobility.

Although any of the required services could be performed by a properly instructed

person, that person would not have the capability to understand the relationship among

the services and their effect on each other. Since the nature of the patient’s condition, his

age and his immobility create a high potential for serious complications, such an

understanding is essential to assure the patient’s recovery and safety. The management

of this plan of care requires skilled nursing personnel until such time as skilled care is no

longer required in coordinating the patient’s treatment regimen, even though the

individual services involved are supportive in nature and do not require skilled nursing

personnel. The documentation in the medical record as a whole is essential for this

determination and must illustrate the complexity of the unskilled services that are a

necessary part of the medical treatment and which require the involvement of skilled

nursing personnel to promote the stabilization of the patient's medical condition and

safety.

EXAMPLE 2:

An aged patient is recovering from pneumonia, is lethargic, is disoriented, has residual

chest congestion, is confined to bed as a result of his debilitated condition, and requires

restraints at times. To decrease the chest congestion, the physician has prescribed

frequent changes in position, coughing, and deep breathing. While the residual chest

congestion alone would not represent a high risk factor, the patient’s immobility and

confusion represent complicating factors which, when coupled with the chest congestion,

could create high probability of a relapse. In this situation, skilled overseeing of the

nonskilled services would be reasonable and necessary, pending the elimination of the

chest congestion, to assure the patient’s medical safety. The documentation in the

medical record as a whole is essential for this determination and must illustrate the

complexity of the unskilled services that are a necessary part of the medical treatment and

which require the involvement of skilled nursing personnel to promote the patient's

recovery and medical safety in view of the patient's overall condition.