(1) The goal of skilled care is to provide care for patients who require general medical management and skilled nursing care on a continuing basis, but who do not require the constant availability of physician services ordinarily found only in the hospital setting.

(2) Skilled nursing care includes components which distinguish it from supportive care. Supportive care does not require professional health training. One component is the observation and assessment of the total needs of the patient. Another component is the rendering of direct services to a patient where the ability to provide the services requires specialized training, such as a registered or a licensed practical nurse.

(3) In evaluating whether the services required by the patient are the continuous skilled services which constitute skilled care, several basic principles are considered.

(a) Since skilled care represents skilled nursing care on a continuous basis, the need for a single skilled service -- for example, intramuscular injections twice a week -- would rarely justify a finding that the care constitutes skilled care.

(b) The classification of a particular service as skilled is based on the technical or professional health training required to effectively perform or supervise the service. For example, a patient, following instructions, can normally take oral medication. Consequently, the act of giving an oral medication to a patient who is too senile to take it himself would not be skilled service, even when a licensed nurse gives the medication.

(c) The importance of a particular service to an individual patient does not necessarily make it a skilled service. For example, a primary need of a non-ambulatory patient may be frequent changes of position in order to avoid development of decubiti. If changing the patient's position is the only regular and frequent service provided, it would not be a skilled service. Routine prophylactic and palliative skin care such as bathing, application of creams, etc. does not constitute skilled services. Presence of a small decubitus ulcer, rash or other relatively minor skin irritation does not generally indicate a need for skilled care. Existence of extensive decubiti or other widespread skin disorder may necessitate skilled care. Physicians' orders for treating the skin, rather than diagnosis, are the principal indication of whether skilled care is required.

(d) The possibility of adverse effects from improper performance of an otherwise unskilled service -- for example, improper transfer of patients from bed to wheelchair -- does not change it to a skilled service.

(4) Any of the following treatment services or care indicate need for skilled nursing care:

(a) oral administered medications requiring constant changes of dosage upon sudden undesirable side effects;

(b) oral medication before routine dosage established and must be watched for reactions;

(c) gastrostomy feedings;

(d) nasopharyngeal aspiration;

(e) recent postoperative colostomy and ileostomy care;

(f) repeated catheterizations during recent postoperative period;

(g) special services in application of dressings involving prescribed medications;

(h) initial phases of operation of inhalation equipment;

(i) physical therapy directed by the physician;

(j) intravenous or instramuscular injections except for the well controlled diabetic;

(k) patient on narcotics for pain;

(l) the very hostile, belligerent and demanding patient who is disruptive to other patients and staff, constantly refusing to take medication or treatment, may be destructive, may attack other patients or personnel, may have frequent periods of agitation and needs constant and close supervision; and

(m) the patient with severe impairments, or who is so withdrawn to the degree that he no longer can communicate and his needs must be anticipated.