Specialized Care – Health and Sensory Disabilities

Section 146.1025  Specialized Care  – Health and Sensory Disabilities These specialized services refer to three categories (Levels) of care which some individuals must receive, fully or in part, in order to attain physical health and development.  The delivery of specialized care in accordance with an individual's needs, as determined by the IDT's assessment, enables the individual to participate in the individual program plan (IPP) and be supported toward greater independence.  Additional reimbursement is paid for an individual who needs and receives services for health and sensory disabilities (Section 146.1035(c)(2)), when those services meet the criteria under subsections (b), (c) or (d). a)         Definitions 1)         Ambulatory – The individual is capable of walking without assistance or the aid of adaptive equipment or devices. 2)         Mobile nonambulatory – The individual is capable of locomotion with mobility assistance such as adaptive equipment or devices. 3)         Nonmobile – The individual is not capable of locomotion even with mobility assistance. b)         Specialized Care, Level I.  The individual is ambulatory, mobile nonambulatory, or has the potential to become mobile nonambulatory, and requires services to compensate for a sensory disability (auditory or visual), or services enabling the individual to be mobile, or limited services to meet medical needs. 1)         Sensory Disabilities A)        Visual Disabilities.  The individual requires and receives specialized services due to a visual disability as defined in Section 146.1035(c)(2)(B)(i). Aids and appliances for individuals having such disabilities are limited to the following items with which facility staff can assist the individual: i)          Cane or dog used in mobility training or a sighted guide; and ii)         Visual aids. B)        Auditory Disabilities.  The individual requires and receives specialized care due to an auditory disability as defined in Section 146.1035(c)(2)(B)(ii).  Aids and appliances for individuals having such disabilities are limited to the following items with which facility staff can assist the individual: i)          Aided augmentative communication system.  Aided modes of communication may include the use of an eye gaze communication board, or an electronic communication device that has speech output or a print tape; ii)         Assistive listening device (hearing aid); and iii)        A hearing dog. AGENCY NOTE:  An individual's treatment might need to include being desensitized to tolerate the use of a hearing aid or assistive listening device to prevent the device from being rejected or destroyed. 2)         Physical Disabilities. The individual requires and receives specialized care and training related to a physical disability which prevents or limits mobility.  The individual becomes mobile when employing certain adaptive equipment.  Aids, appliances and other adaptive equipment which promote mobility for individuals with physical disabilities are limited to the following devices which individuals can be taught to apply, or can be applied with assistance from facility staff: A)        Arm brace; B)        Back brace, body jacket; C)        Leg brace; D)        Prosthesis; E)        Splints; F)         Adaptive wheelchair; and G)        Walker. AGENCY NOTE:  A physical disability is defined as a physical impairment which results in a functional disability, such as spasticity, poor muscle tone, paralysis, and absence of limbs.  Eligibility under Physical Disabilities requires that the individual needs training in the use of a device or devices in order to achieve some level of independent mobility. An individual who is already independent in mobility and requires adaptive equipment does not qualify.  This includes some individuals who are in training programs for deficits in gross or fine motor functioning, and some individuals who are not in such training programs. c)         Specialized Care, Level II.  The individual is nonmobile, or mobile nonambulatory, requires mobility assistance, and requires services to meet high personal care needs. The individual may also have significant daily medical needs, and may have dual sensory disabilities (visual and auditory). 1)         High Personal Care/Mobility Need (nonmobile). The individual requires and receives partial or total assistance in bathing, clothing, grooming and hygiene, eating and toileting/continence. The individual requires and receives mobility assistance, due to a functional deficit (as determined by physical or psychological causes), to transfer from a bed to an alternative positioning device.  The individual also requires and receives assistance with movement/mobility around the facility. The individual may require position changes at two hour intervals, or as specified in the individual program plan, or range of motion twice a day or as specified in the individual program plan. 2)         Medical Need A)        The individual requires and receives insulin injections daily or more frequently for the management of diabetes which is not stabilized.  Daily monitoring by licensed personnel is required to assess the individual's status, side effects, laboratory work, and to report to the physician as necessary.  The requirement for monitoring pertains also to insulin which is administered on a sliding scale basis.  This monitoring results in adjustments in dosage or type of insulin, as indicated by the individual's status. B)        The individual needs and receives ostomy care for a jejunostomy, an ileostomy, or a colostomy. 3)         Dual Sensory Disabilities. The individual requires and receives services as required, due to both an auditory disability and a visual disability. d)         Specialized Care, Level III. The individual is typically nonmobile or mobile nonambulatory, but may be ambulatory, and requires services to meet high medical needs.  High medical needs means one or more of the following: 1)         The individual requires and receives intermittent catheterization more than twice a day. A)        Daily recording of intake and output is required. B)        Infection control measures must be carried out as indicated in the facility's catheterization protocol. 2)         The individual requires and receives respiratory care which includes: tracheostomy care, positive pressure breathing treatments, aerosol therapy, postural drainage with percussion, vibration or suctioning. A)        The respiratory status of the individual receiving respiratory care must be frequently assessed as required by the IPP. B)        Infection control measures must be carried out as indicated in the facility's respiratory procedure protocol. 3)         The individual requires and receives feeding via a nasogastric or gastrostomy tube, or, the individual has poor sucking or swallowing reflexes and requires and receives prolonged oral feeding of two or more hours daily. 4)         The individual requires and receives wound care, having been admitted to the facility with a stage III or IV decubitus ulcer, or has deep wounds, infected wounds, extensive burns or extensive lesions requiring treatment in the form of medications, dressings, whirlpool, ultraviolet light or irrigations. A)        Decubitus ulcer management includes turning, positioning, nutritional support, range of motion exercises, supportive devices and infection control. B)        The facility protocol for decubitus ulcer prevention must be adhered to. 5)         The individual requires and receives intensive physical habilitation due to a functional deficit (as determined by physical or psychological causes). A)        Intensive physical habilitation occurs throughout the individual's working hours to promote skill acquisition. B)        The individual requires and receives intensive contracture prevention via "hands on" assistance. C)        When staff is meeting functional and service needs of an individual, that time should be used for priority objective/goal attainment.  For example, when the individual has been repositioned, staff stimulation should occur, or the individual is ambulated with assistance to the bathroom or the dining room rather than taken in a wheelchair. AGENCY NOTE:  Range of motion to all extremities as indicated in the IPP should be incorporated into the individual's daily routine/programs (dressing, bathing, feeding, etc.).