The following sections list those services commonly furnished by nursing personnel in skilled nursing homes and their usual skill classification. Any generally non-skilled service could, because of special medical complications in an individual case, require skilled performance, supervision or observation. However, the complications and special services involved should be documented by nursing notes and/or physician orders with progress notes. These records should include the observations made of physical findings, new developments in the course of the disease, the carrying out of details of treatment prescribed, and the results of the treatment.

(1) Medications given by intravenous or intramuscular injections usually require skilled services. The frequency of injections would be particularly significant in determining whether the patient needs continuous skilled nursing care. Injections which can usually be self-administered -- for example, the well-regulated diabetic who receives a daily insulin injection -- do not require skilled services. Oral medications which require immediate changes in dosages because of sudden undesirable side effects or reactions should be administered to the patient and observed by licensed nurses, e.g., anti-coagulants, quinidine. This is a skilled service. Where a prolonged regimen of oral drug therapy is instituted, the need for continued presence of skilled nursing personnel can be presumed only during the period in which the routine is being established and changes in dosage cannot be anticipated or accomplished by unskilled personnel, e.g., digitalis.

(a) Administration of eye drops and topical ointments (including those required following cataract surgery) is not a skilled service. In Montana, institutional patients must receive all medications from licensed nurses; this fact, however, would not make the administration of oral medication a skilled service where the same type of medications are frequently prescribed for home use without skilled personnel being present.

(2) Levine tube and gastrostomy feedings must be properly prepared and administered. Supervision and observation by licensed nurses are required, thus making this procedure a skilled service.

(3) The services and observation required for nasopharyngeal aspiration constitute skilled nursing care.

(4) Colostomy or ileostomy may require skilled service during the immediate postoperative period following a newly created or revised opening. The need for such care should be documented by a physician and nursing notes. General maintenance care of this condition can usually be performed by the patient himself or by a person without professional raining and would not usually require skilled services.

(5) Repeated catheterizations during the immediate post-operative period following abdominal surgery could, with a few other skilled services, constitute continuous skilled nursing care. Routine services in connection with indwelling bladder catheters do not constitute skilled care. Catheters used in other parts of the body, such as bile ducts, chest cavity, etc., require skilled care.

(6) General methods of treating incontinence, such as use of diapers and rubber sheets, are not skilled services. A catheter used for incontinence would not require skilled care. Secondary skin problems should indicate the treatment required and should be noted in the patient's record.

(7) Special service in connection with application of dressings involving prescription medications and aseptic technique constitute skilled services. Routine changes of dressings, particularly in non-infected postoperative or chronic conditions, generally do not require skilled services or supervision.

(8) Routine care in connection with braces and similar devices appliances does not constitute skilled services. Care involving training in proper use of a particular appliance should be evaluated in relation to the need for physical therapy.

(9) The use of protective restraints generally does not require services of skilled personnel. This includes such devices as bed rails, soft binders, and wheelchair patient supports.

(10) Any regimen involving regular administration of inhalation therapy can be instituted only upon specific physician order. The initial phases of instituting such a regimen would be skilled care. However, when such administration becomes a part of regular routine, it would not generally be considered a skilled service since patients can usually be taught to operate their own inhalation equipment, or non-skilled personnel can supervise its administration, as in cases of chronic asthma, emphysema, etc.

(11) Physical therapy, one aspect of restorative care, consists of the application of a complex and sophisticated group of physical modalities and therapeutic services. Physical therapy, therefore, is a skilled service. However, a provision of physical therapy only would not justify a finding that the patient requires skilled care. In some situations, however, a patient whose primary need is for physical therapy will also require sufficient skilled nursing to meet the definition of skilled care. The need for such supportive skilled nursing on a continuing basis may be presumed when all four of the following conditions are met.

(a) The therapy is directed by the physician who determines the need for therapy, the capacity and tolerance of the patient, and the treatment objectives.

(b) The physician, in consultation with the therapist, prescribes the specific modalities to be used and frequency of therapy services.

(c) The therapy is rendered by or under the supervision of a physical therapist who meets the qualifications established by regulations; when the qualified therapist is the supervisor, he is available and on the premises of the facility while the therapy is being given, he makes regular and frequent evaluations of the patient, records findings on the patient's chart, and communicates with the physician as indicated.

(d) The therapy is actively concerned with restoration of a lost or impaired function. For example, frequent physical therapy treatments in connection with a fractured back or hip or a CVA can be presumed to be directed toward restoration of lost or impaired function during the early phase --when physical therapy can be presumed to be effective. However, when the condition has stabilized, the presumption that continuing supportive skilled nursing services are required is no longer valid. Such cases must be evaluated in relation to the specific amount of skilled nursing attention required in the individual case as evidenced by physician orders and nursing notes. The routine ambulation and/or transfer of patients is not a skilled service.