Presented by: Mary Ann Knee RN,CRNI, COS-C

Presented by: Mary Ann Knee RN,CRNI, COS-C 64B9-12.002 Definitions. (1) Administration of Intravenous Therapy is the therapeutic infusion and/or injection of substances through the venous peripheral system, consisting of activity which includes: observing, initiating, monitoring, discontinuing, maintaining, regulating, adjusting, documenting, planning, intervening and evaluating. KNEE,&MARY&ANN&1&

Infusion Therapy to increase revenue base Develop a niche in the home care market Meet the needs of a current referral source TPN (supplies paid for under the DME as a prosthetic Antibiotics Hydration Pain management Chemotherapy Ionotropics Steroids Antifungals KNEE,&MARY&ANN&2&

Cancer CHF Crohn s Disease Hemophelia Immune deficiencies MS Rheumatoid Arthritis Cellulitis Sepsis Osteomyelitis UTI Pneumonia Sinusitis Although drugs and biologicals are specifically excluded from coverage by the statute ( 1861(m)(5) of the Act, the services of a nurse that are required to administer the medications safely and effectively may be covered if they are reasonable and necessary to the treatment of the illness or injury KNEE,&MARY&ANN&3&

Injections (coverage in Medicare Benefit Manual under injections) Intravenous, intramuscular, or subcutaneous injections and infusions, and hypodermoclysis or intravenous feedings require the skills of a licensed nurse to be performed (or taught) safely and effectively. Where these services are reasonable and necessary to treat the illness or injury, they may be covered. For these services to be reasonable and necessary, the medication being administered must be accepted as safe and effective treatment of the patient's illness or injury, and there must be a medical reason that the medication cannot be taken orally.. KNEE,&MARY&ANN&4&

Moreover, the frequency and duration of the administration of the medication must be within accepted standards of medical practice, or there must be a valid explanation regarding the extenuating circumstances to justify the need for the additional injections Antibiotic regimens very often require peak and trough as well as other labs Parenteral nutrition requires management of electrolytes as well as other labs Are they covered? KNEE,&MARY&ANN&5&

40.1.2.13 - Venipuncture (Rev. 1, 10-01-03) A3-3118.1.B.13, HHA-205.1.B.13 Effective February 5, 1998, venipuncture for the purposes of obtaining a blood sample can no longer be the sole reason for Medicare home health eligibility. KNEE,&MARY&ANN&6&

If a beneficiary qualifies for home health eligibility based on a skilled need other than solely venipuncture (e.g., eligibility based on the skilled nursing service of wound care and meets all other Medicare home health eligibility criteria), medically reasonable and necessary venipuncture coverage may continue during the 60-day episode under a home health plan of care. Sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act specifically exclude venipuncture, as a basis for qualifying for Medicare home health services if this is the sole skilled service the beneficiary requires. However, the Medicare home health benefit will continue to pay for a blood draw if the beneficiary has a need for another qualified skilled service and meets all home health eligibility criteria. KNEE,&MARY&ANN&7&

If a beneficiary qualifies for home health eligibility based on a skilled need other than solely venipuncture (e.g., eligibility based on the skilled nursing service of wound care and meets all other Medicare home health eligibility criteria), medically reasonable and necessary venipuncture coverage may continue during the 60-day episode under a home health plan of care. This specific requirement applies to home health services furnished on or after February 5, 1998. KNEE,&MARY&ANN&8&

For venipuncture to be reasonable and necessary: The physician order for the venipuncture for a laboratory test should be associated with a specific symptom or diagnosis, or the documentation should clarify the need for the test when it is not diagnosis/illness specific. In addition, the treatment must be recognized (in the Physician's Desk Reference, or other authoritative source) as being reasonable and necessary to the treatment of the illness or injury for venipuncture and monitoring the treatment must also be reasonable and necessary. KNEE,&MARY&ANN&9&

The frequency of testing should be consistent with accepted standards of medical practice for continued monitoring of a diagnosis, medical problem, or treatment regimen. Even where the laboratory results are consistently stable, periodic venipuncture may be reasonable and necessary because of the nature of the treatment. An unstable insulin dependent or noninsulin dependent diabetic would require FBS more frequently than once per month if ordered by the physician. Where there is a new diagnosis or where there has been a recent exacerbation, but the patient is not unstable, monitoring once per month would be reasonable and necessary. KNEE,&MARY&ANN&10&

Where the results are stable within the therapeutic ranges, monthly monitoring would be reasonable and necessary. Where the results are stable within nontherapeutic ranges, there must be documentation of other factors which would indicate why continued monitoring is reasonable and necessary. What labs are frequently performed for patients receiving infusions? CBC CMP Electrolytes Pharmacokinetics for antibiotics Drug levels Trace metals for TPN KNEE,&MARY&ANN&11&

50.4 - Medical Supplies (Except for Drugs and Biologicals Other Than Covered Osteoporosis Drugs) and the Use of Durable Medical Equipment (Rev.26, Issued 11-05-04, Effective: 01-01-05, Implementation: 04-04-05) 50.4.1 - Medical Supplies (Rev. 1, 10-01-03) A3-3119.4.A, HHA-206.4.A Medicare pays for the nursing Who pays for the supplies? Supplies are bundled as a medical supply 50.4 - Medical Supplies (Except for Drugs and Biologicals Other Than Covered Osteoporosis Drugs) & the Use of Durable Medical Equipment (Rev.26, Issued 11-05-04, Effective: 01-01-05, Implementation: 04-04-05) 50.4.1 - Medical Supplies (Rev. 1, 10-01-03) A3-3119.4.A, HHA-206.4.A KNEE,&MARY&ANN&12&

Medical supplies are items that, due to their therapeutic or diagnostic characteristics, are essential in enabling HHA personnel to conduct home visits or to carry out effectively the care the physician has ordered for the treatment or diagnosis of the patient's illness or injury. All supplies which would have been covered under the cost-based reimbursement system are bundled under home health PPS. Payment for the cost of supplies has been incorporated into the per visit and episode payment rates. KNEE,&MARY&ANN&13&

Routine - because they are used in small quantities for patients during the usual course of most home visits; or Non-routine - because they are needed to treat a patient's specific illness or injury in accordance with the physician's plan of care and meet further conditions discussed in more detail below. All HHAs are expected to separately identify in their records the cost of medical and surgical supplies that are not routinely furnished in conjunction with patient care visits and the use of which are directly identifiable to an individual patient. KNEE,&MARY&ANN&14&

50.4.1.1 - The Law, Routine and Nonroutine Medical Supplies, and the Patient's Plan of Care (Rev. 1, 10-01-03) A3-3119.4A.2, HHA-206.4A3, 4, 5 The Medicare law governing the home health PPS is specific to the type of items and services bundled to the HHA and the time the services are bundled. Medical supplies are bundled while the patient is under a home health plan of care KNEE,&MARY&ANN&15&

HHA is required to provide the medical supply while the patient is under a home health plan of care during an open episode. The physician orders in the plan of care must reflect all nonroutine medical supplies provided and used while the patient is under a home health plan of care during an open 60-day episode. The consolidated billing requirement is not superseded by the exclusion of certain medical supplies from the plan of care and then distinguishing between medical supplies that are related and unrelated to the plan of care. Failure to include medical supplies on the plan of care does not relieve HHAs from the obligation to comply with the consolidated billing requirements. The comprehensive nature of the current patient assessment and plan of care requirements looks at the totality of patient needs. KNEE,&MARY&ANN&16&

There could be a circumstance where a physician could be uncomfortable with writing orders for a preexisting condition unrelated to the reason for home health care. In those circumstances, PRN orders for such supplies may be used in the plan of care by a physician. Primary physician would not need to order supplies for infusion, the specialist can write the order All medical supplies are bundled while the patient is under a home health plan of care during an open 60-day episode. This includes, but is not limited to, the above listed medical supplies as well as the Part B items provided in the final PPS rule. The latter item lists are subsequently updated in accordance with the current process governing the deletion, replacement and revision of Medicare Part B codes. KNEE,&MARY&ANN&17&

Both Medicare and Veteran's Administration (VA) benefits are primary. The beneficiary who is a veteran has some choices in cases where the benefits overlap. The beneficiary must select one or the other program as primary when obtaining active care. If the VA is selected as primary for home health care, then Medicare becomes a secondary payer. An HHA must provide the medical supplies a Medicare beneficiary needs no matter the payer; it is not obligated to provide medical supplies that are not needed KNEE,&MARY&ANN&18&

If a patient has medical supplies provided by the VA because of the patient's preference, then the HHA must not duplicate the supplies under Medicare. The beneficiary's choice is controlling. The HHA may not require the beneficiary to obtain or use medical supplies covered by the primary payer from any other source, including the VA. 50.4.1.3 Non-routine Supplies (Reportable) (Rev. 1, 10-01-03) A3-3119.4.A.2, HHA-206.4.A.2 The item is recognized as having the capacity to serve a therapeutic or diagnostic purpose in a specific situation; and The item is required as a part of the actual physician-prescribed treatment of a patient's existing illness or injury KNEE,&MARY&ANN&19&

Non-routine supplies are identified by the following conditions: 1. The HHA follows a consistent charging practice for Medicare and other patients receiving the item; 2. The item is directly identifiable to an individual patient; 3. The cost of the item can be identified and accumulated in a separate cost center; And 4. The item is furnished at the direction of the patient's physician and is specifically identified in the plan of care. KNEE,&MARY&ANN&20&

All non-routine supplies must be specifically ordered by the physician or the physician's order for services must require the use of the specific supplies to be effectively furnished. The charge for nonroutine supplies is excluded from the per visit costs. Dressings/Wound Care Sterile dressings; Sterile gauze & toppers; Kling and Kerlix rolls; Telfa pads; Eye pads; Sterile solutions, ointments; Sterile applicators; & Sterile gloves. I.V. Supplies Ostomy Supplies Catheters & Catheter Supplies to name a few KNEE,&MARY&ANN&21&

Yes they are! The infusion pharmacy will bill the agency Remember to include the supplies in your RAP and Final billing AHCA CMS Florida Nurse Practice Act Accrediting Organizations such as: CHAP ACHC The Joint Commission Remember you are providing specialized care and are held to the standards of the clinical specialty such as the Infusion Nurses Society and the Oncology Nursing Society KNEE,&MARY&ANN&22&

Standards of Practice for INS Keep a copy of the current standards available Policies and Procedures INS has policies & procedures that have been written according to the standards Is intended to reflect current knowledge & practices of the clinical nursing specialty of infusion therapy. Because clinical practice continually evolves based on ongoing research, users should make an independent assessment of the appropriateness & applicability of a standard in any specific instance, & should also consider the applicable federal and state laws and regulations, as well as the standard of care in a particular jurisdiction, as these may take precedence. KNEE,&MARY&ANN&23&

INS is not responsible for injury to persons or property, or other harm, arising from the use of the Standards. RNs must be proficient in performance of all aspects of infusion therapy LPNs must have 30 hour continuing education program including management of central lines If LPNs are performing visits for infusion, there must be an RN available with infusion experience for consultation KNEE,&MARY&ANN&24&

(1) The practice of practical nursing as defined by Section 464.003(3)(b), Florida Statutes, includes the administration of treatments and medication, under direction, and holds the licensed practical nurse responsible & accountable for making decisions...based upon the individual s educational preparation & experience in nursing. As medical science advances and the demands for health care in Florida grow, the scope of nursing practice, in general, & of the practice of practical nursing, in particular, is expanding. when qualified by training and education and when approved by the institution at which the licensed practical nurse is employed, engage in the limited administration of intravenous therapy both to serve the public and to allow the professional nurse to better perform those acts requiring professional nursing specialized knowledge, judgment and skill.. KNEE,&MARY&ANN&25&

(2) The purpose of this rule is to protect the public by ensuring the availability of intravenous therapy and its competent administration in the care of the ill, injured or the infirm the qualified licensed practical nurse to administer those aspects of intravenous therapy within the scope of practice of the licensed practical nurse, enumerates those aspects of intravenous therapy outside the scope of practice of the licensed practical nurse, & sets out the educational and/or competency verification necessary to administer, under direction, limited forms of intravenous therapy KNEE,&MARY&ANN&26&

means that the registered professional nurse has delegated intravenous therapy functions to a qualified licensed practical nurse. The registered professional nurse does not in all instances have to be on the premises in order for the licensed practical nurse to perform the delegated functions. (3) Direct supervision means on the premises and immediately physically available. (1) Aspects of intravenous therapy which are outside the scope of practice of the licensed practical nurse unless under the direct supervision of the registered professional nurse or physician and which shall not be performed or initiated by licensed practical nurses without direct supervision include the following: KNEE,&MARY&ANN&27&

(a) Initiation of blood and blood products; (b) Initiation or administration of cancer chemotherapy; (c) Initiation of plasma expanders; (d) Initiation or administration of investigational drugs; (e) Mixing IV solution; (f) IV pushes, except heparin flushes and saline flushes. (2) Although this rule limits the scope of licensed practical nurse practice, it is appropriate for licensed practical nurses to care for patients receiving such therapy. KNEE,&MARY&ANN&28&

The board endorses the Intravenous Therapy Course Guidelines issued by the Education Department of the National Federation of Licensed Practical Nurses, November, 1983. The intravenous therapy education must contain the following components: Policies and procedures of both the Nurse Practice Act and the employing agency in regard to intravenous therapy. This includes legalities of both the Licensed Practical Nurse role and the administration of safe care. Principles of charting are also included. KNEE,&MARY&ANN&29&

Psychological preparation and support for the patient receiving IV therapy as well as the appropriate family members/ significant others. (c) Site and function of the peripheral veins used for veinpuncture. (d) Procedure for veinpuncture, including physical and psychological preparation, site selection, skin preparation, palpation of veins, and collection of equipment. Relationship between intravenous therapy and the body s homeostatic and regulatory functions, with attention to theclinical manifestations of fluid and electrolyte imbalance. f) Signs and symptoms of local and systemic complications in the delivery of fluids and medications and the preventive and treatment measures for these complications.. KNEE,&MARY&ANN&30&

(g) Identification of various types of equipment used in administering intravenous therapy with content related to criteria for use of each and means of trouble shooting for malfunction. (h) Formulas used to calculate fluid and drug administration rate (i) Methods of administering drugs intravenously and advantages and disadvantages of each. (j) Principles of compatibility and incompatibility of drugs and solutions. (k) Nursing management of the patient receiving drug therapy, including principles of chemotherapy, protocols, actions, and side effects. KNEE,&MARY&ANN&31&

(l) Nursing management of the patient receiving blood and blood components, following institutional protocol. Include indications and contraindications for use; identification of adverse reactions. (m) Nursing management of the patient receiving parenteral nutrition, including principles of metabolism, potential complications, and physical and psychological measures to ensure the desired therapeutic effect. (n) Principles of infection control in IV therapy, including aseptic technique and prevention and treatment of iatrogenic infection. KNEE,&MARY&ANN&32&

(o) Nursing management of special IV therapy procedures that are commonly used in the clinical setting, such as heparin lock, central lines, and arterial lines. (p) Glossary of common terminology pertinent to IV fluid therapy. (q) Performance check list by which to evaluate clinical application of knowledge and skills. RNs are expected to meet the competency criteria same as the LPNs since they oversee the care provided by the LPN INS provides an excellent program of testing the competencies of RNs and LPNs in the maintenance of infusion therapy They are available on ins1.org KNEE,&MARY&ANN&33&

The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C. Appropriate education and training requires a minimum of four (4) hours of instruction. The education and training required shall include, at a minimum, didactic & clinical practicum instruction in the following areas: (a) Central venous anatomy & physiology; (b) CVL site assessment; (c) CVL dressing & cap changes; CVL flushing; (d) CVL medication & fluid administration; (f) CVL blood drawing; and (g) CVL complications and remedial measures. KNEE,&MARY&ANN&34&

the Licensed Practical Nurse shall be assessed on both theoretical knowledge and practice, as well as clinical practice and competence. The clinical practice assessment must be witnesses by an RN who shall file a proficiency statement regarding the LPN s ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurse s personnel file shall be the responsibility of each institution employing a licensed practical nurse based on institutional protocol. Such verification shall be given through a signed statement of a Florida licensed registered nurse. KNEE,&MARY&ANN&35&

Every effort should be made to have the patient discharged early in the day to establish a workable schedule Evening discharges impact your ability to schedule clinicians Prior to discharge, establish a realistic expectation for the patient or caregiver to participate in the administration of the therapy to prevent an outlier situation. I have the patient/caregiver sign a responsibility statement If multiple visits are need daily, arrange for a pump if able to do so. Be aware you need to pay for the daily rental of the pump as well Be prepared to negotiate with the for an acceptable per diem rate. Be aware even once you have a family member trained, the per diem rate continues and the costs mount up KNEE,&MARY&ANN&36&

Competencies Cost of supplies Scheduling issues On call RN for questions and complications Competencies Cost of supplies Scheduling issues On call RN for questions and complications KNEE,&MARY&ANN&37&

Infusion Therapy, Should I or Shouldn t I? Thank you! Questions? KNEE,&MARY&ANN&38&