Section 340. Pediatric and adolescent specialized care criteria

§ 3.0 General description. The child must have ongoing health conditions requiring close medical supervision, 24 hours licensed nursing supervision, AND specialized services or equipment. The recipient must be age 21 or under.

§ 3.1 Targeted population.

A. Children requiring mechanical ventilation

B. Children with communicable diseases requiring universal or respiratory precautions (excluding normal childhood diseases such as chicken pox, measles, strep throat, etc.)

C. Children requiring ongoing intravenous medication or intravenous nutrition administration

D. Children requiring daily dependence on device based respiratory or nutritional support (tracheostomy, gastrostomy, etc.)

E. Children requiring comprehensive rehabilitative therapy service

F. Children with terminal illness

§ 3.2 Criteria.

A. The child must require at a minimum:

1. Physician visits at least once weekly (the initial physician visit must be made by the physician personally. Subsequent required physician visits after the initial visit may alternate between personal visits by the physician and visits by a physician assistant or nurse practitioner.)

2. Skilled nursing services 24 hours a day (a registered nurse must be on the nursing unit on which the child is residing, 24 hours a day, whose sole responsibility is that nursing unit)

3. Coordinated multidisciplinary team approach to meet needs

4. The nursing facility must coordinate with appropriate state and local agencies for the educational and habilitative needs of the child. These services must be age appropriate and appropriate to the cognitive level of the child. Services must also be individualized to meet the specific needs of the child and must be provided in an organized and proactive manner. Services may include but are not limited to school, active treatment for mental retardation, habilitative therapies, social skills and leisure activities. The services must be provided for a total of 2 hours per day, minimum.

B. In addition, the child must meet one of the following requirements:

1. Must require two out of three of the following rehabilitative services: Physical Therapy, Occupational Therapy, Speech-pathology services; therapy must be provided at a minimum of 6 therapy sessions (minimum of 15 minutes per session) per day, 5 days per week; child must demonstrate progress in overall rehabilitative plan of care on a monthly basis; or

2. Must require special equipment such as mechanical ventilators, respiratory therapy equipment (that has to be supervised by licensed nurse or respiratory therapist), monitoring device (respiratory or cardiac) kinetic therapy, etc., or

3. Children that require at least one of the following special services:

a. Ongoing administration of intravenous medications of nutrition (i.e., TPN, antibiotic therapy, narcotic administration, etc.)

b. Special infection control precautions (universal or respiratory precaution; this does not include handwashing precautions only or isolation for normal childhood diseases such as measles, chicken pox, strep throat, etc.)

c. Dialysis treatment that is provided within the facility (i.e., peritoneal dialysis)

d. Daily respiratory therapy treatments that must be provided by a skilled nurse or respiratory therapist

e. Extensive wound care requiring debridement, irrigation, packing, etc., more than two times a day (i.e., grade IV decubiti; large surgical wounds that cannot be closed, second or third degree burns covering more than 10% of the body)

f. Ostomy care requiring services by a licensed nurse

g. Care for terminal illness

Historical Notes

Derived from VR460-03-3.1301 § 3, eff. June 29, 1994.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.