Part XLVII. Nurses: Practical Nurses and Registered Nurses

Chapter 37. Nursing Practice

A. Registered nurses, who are not certified registered nurse anesthetists, may administer anesthetic agents to intubated patients in critical care settings, and may titrate and continue infusion of local anesthetic agents through the use of epidural catheters for pain management, excluding obstetric patients, provided that the following conditions are met.

1. There is an institutional policy and plan for registered nurses (non-CRNAs) to administer anesthetic agents to intubated patients in critical care settings, and to titrate and continue infusion of local anesthetic agents through the use of epidural catheters and perineural catheters for pain management for patients other than obstetric patients that includes:

a. a clear statement of the purpose and goal of the treatment;

b. written protocols, with documentation of acceptance of the protocols by the medical staff of the agency;

c. policies and procedures to include but not be limited to the following:

i. preparation of solution;

ii. initiation of infusion;

iii. responding to emergency situations;

iv. maximum dose per hour of an anesthetic agent which can be administered by a registered nurse, who is not a certified registered nurse anesthetist, as approved by the medical staff; and

v. criteria for documentation of the procedure.

2. No anesthetic agent may be administered by a registered nurse, who is not a certified registered nurse anesthetist pursuant to this part unless there is a medical order by an authorized prescriber. Any orders to change the rate of infusion must be a medical order or in lieu of a specific order to change the rate of infusion, there are clearly stated criteria, by the authorizing prescriber, for adjusting the rate of infusion. However, in an emergency situation, the registered nurse may decrease the rate of infusion before calling the authorized prescriber.

B. Further, registered nurses, who are not certified registered nurse anesthetists, may titrate and continue infusion of local anesthetic agents through the use of epidural catheters and perineural catheters for pain management, excluding obstetric patients, provided that the following conditions are met.

1. There is documentation that the registered nurse has successfully completed a course of instruction, which includes but is not limited to didactic instruction and supervised clinical practice on the following:

a. anatomy and physiology of the spinal cord and column and neurological system;

b. purpose of the epidural and perineural catheter for pain management;

c. catheter placement and signs and symptoms of misplacement;

d. effects of medication administered epidurally and perineurally;

e. untoward reaction to medication and management;

f. complications; and

g. nursing care responsibilities:

i. observation;

ii. procedures;

iii. catheter maintenance;

iv. proper calibration and operation of infusion pump; and

v. removal of the epidural or perineural catheter.

2. Competencies shall be measured initially during orientation and on an annual basis.

C. The administration of anesthetic agents to intubated patients in critical care settings, and the titration and continuance of infusion of local anesthetic agents through the use of epidural and perineural catheters for pain management for patients may not be delegated or assigned by a registered nurse to anyone other than a registered nurse who meets the criteria set forth in this standard.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:935.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Board of Nursing, LR 32:246 (February 2006), amended 37:

In compliance with R.S. 49:953 and 974, the following Family Impact Statement of the proposed amendments to

Rules is provided. There should be no adverse effect on the stability of the family; the authority and rights of parents regarding the education and supervision of their children; or the ability of the family or a local government to perform the function as contained in the proposed Rule amendments.

Public Comments

Interested persons may submit written comments on the proposed Rule until 5 p.m., January 10, 2010 to Barbara L. Morvant, Executive Director, 17373 Perkins Road, Baton Rouge, LA 70810.

Executive Director

There is no anticipated increase or decrease in expenditures or savings except for the cost of printing, which is estimated at $300.00 in FY 10-11.

II. ESTIMATED EFFECT ON REVENUE COLLECTIONS OF STATE OR LOCAL GOVERNMENTAL UNITS (Summary)

There is no estimated effect on revenue collections.

III. ESTIMATED COSTS AND/OR ECONOMIC BENEFITS TO DIRECTLY AFFECTED PERSONS OR NONGOVERNMENTAL GROUPS (Summary)

It is anticipated that there will be an economic benefit to hospitals that may otherwise require that a certified registered nurse anesthetist (CRNA) or an anesthesiologist leave their operating/surgical area to attend to patients in the orthopedic section of hospital in order to administer local anesthetic agents through a perineural catheter. Through this rule, registered nurses (RNs) already on-hand at the hospital, who have received the requisite training, will be allowed to administer the anesthesia through a perineural catheter if the CRNA or anesthesiologist are unavailable. Registered nurses will have to undergo additional training in the use, care, and maintenance of perineural catheters, including instruction and supervised clinical practice. Also, they will have to undergo additional instruction on the neurological system. As such, the employing hospital will have to fund the necessary training expenses and clinical supervision necessary for RNs who will be partaking in this service. This will occur mostly for RNs in post-surgical units.

IV. ESTIMATED EFFECT ON COMPETITION AND EMPLOYMENT (Summary)

The impact on competition and employment is negligible. While the law revision and proposed rule provide for registered nurses who are not CRNAs to titrate and continue infusion of local anesthetic agents through the use of perineural catheters, this should not impact competition or employment of CRNAs. Instead, the rule allows RNs, who have been properly educated and prepared in the procedure, to provide the needed patient services in a cost efficient manner and allow the CRNA to be available for their responsibilities in more complex situations

All Inclusive Care for the Elderly

The Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Aging and Adult Services propose to amend LAC 50:XXIII.1301 in the Medical Assistance Program as authorized by R.S. 36:254 and pursuant to Title XIX of the Social Security Act and as directed by Act 11 of the 2010 Regular Session of the Louisiana Legislature which states: “The secretary is directed to utilize various cost containment measures to ensure expenditures in the Medicaid Program do not exceed the level appropriated in this schedule, including but not limited to precertification, preadmission screening, diversion, fraud control, utilization review and management, prior authorization, service limitations, drug therapy management, disease management, cost sharing, and other measures as permitted under federal law.” This proposed Rule is promulgated in accordance with the provisions of the Administrative Procedure Act, R.S. 49:950 et seq.

The Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing amended the provisions governing the Program of All Inclusive Care for the Elderly (PACE) to: 1) remove the requirement that eligibility decisions be approved by the state administering agency; 2) revise PACE disenrollment criteria; 3) allow for service area specific rates instead of one statewide rate; and 4) clarify when the obligation for patient liability begins (Louisiana Register, Volume 33, Number 5).

As a result of a budgetary shortfall in state fiscal year 2011, the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Aging and Adult Services promulgated an Emergency Rule which amended the provisions governing the reimbursement methodology for PACE to reduce the capitated amounts paid to PACE organizations (Louisiana Register, Volume 36, Number 8). Due to a continuing budgetary shortfall in state fiscal year 2011, the department promulgated an Emergency Rule which amended the provisions governing the reimbursement methodology for PACE to further reduce the capitated amount paid to PACE organizations (Louisiana Register, Volume 36, Number 12). This proposed Rule is being promulgated to continue the provisions of the August 1, 2010 and the December 1, 2010 Emergency Rules.

A. - J.3. …

K. Effective for dates of service on or after August 1, 2010, the monthly capitated amount paid to a PACE organization shall be reduced by 2 percent of the capitated amount on file as of July 31, 2010.

L. Effective for dates of service on or after December 1, 2010, the monthly capitated amount paid to a PACE organization shall be reduced by 3.09 percent of the capitated amount on file as of November 30, 2010.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254, Title XIX of the Social Security Act and 42 CFR 460 et seq.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 30:250 (February 2004), amended LR 33:850 (May 2007), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 37:

Implementation of the provisions of this Rule may be contingent upon the approval of the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), if it is determined that submission to CMS for review and approval is required.

Family Impact Statement

In compliance with Act 1183 of the 1999 Regular Session of the Louisiana Legislature, the impact of this proposed Rule on the family has been considered. It is anticipated that this proposed Rule may have an adverse impact on family functioning, stability and autonomy as described in R.S. 49:972 in the event that provider participation in the PACE Program is diminished as a result of reduced reimbursement rates.

Interested persons may submit written comments to Don Gregory, Bureau of Health Services Financing, P.O. Box 91030, Baton Rouge, LA 70821-9030. He is responsible for responding to inquiries regarding this proposed Rule.

A public hearing on this proposed Rule is scheduled for Wednesday, January 26, 2011 at 9:30 a.m. in Room 118, Bienville Building, 628 North Fourth Street, Baton Rouge, LA. At that time all interested persons will be afforded an opportunity to submit data, views or arguments either orally or in writing. The deadline for receipt of all written comments is 4:30 p.m. on the next business day following the public hearing.

Secretary

It is anticipated that the implementation of this proposed rule will result in estimated programmatic savings to the state of $87,938 for FY 10-11, $163,464 for FY 11-12 and $169,351 for FY 12-13. It is anticipated that $328 ($164 SGF and $164 FED) will be expended in FY 10-11 for the state's administrative expense for promulgation of this proposed rule and the final rule. The numbers reflected above are based on a blended Federal Medical Assistance Percentage (FMAP) rate of 74.76 percent (in FY 10-11). The enhanced rate of 81.48 percent for the first six months of the fiscal year is authorized by the American Recovery and Reinvestment Act (ARRA) of 2009. To the extent that additional enhanced federal match would be available and appropriated after December 2010 (end of the ARRA eligibility), state general fund match could be reduced in the current fiscal year.

II. ESTIMATED EFFECT ON REVENUE COLLECTIONS OF STATE OR LOCAL GOVERNMENTAL UNITS (Summary)

It is anticipated that the implementation of this proposed rule will reduce federal revenue collections by approximately $260,790 for FY 10-11, $338,729 for FY 11-12 and $347,908 for FY 12-13. It is anticipated that $164 will be expended in FY 10-11 for the federal administrative expenses for promulgation of this proposed rule and the final rule. The numbers reflected above are based on a blended Federal Medical Assistance Percentage (FMAP) rate of 74.76 percent (in FY 10-11). The enhanced rate of 81.48 percent for the first six months of the fiscal year is authorized by the American Recovery and Reinvestment Act (ARRA) of 2009. To the extent that additional enhanced federal match would be available and appropriated after December 2010 (end of the ARRA eligibility), state general fund match could be reduced in the current fiscal year.

III. ESTIMATED COSTS AND/OR ECONOMIC BENEFITS TO DIRECTLY AFFECTED PERSONS OR NONGOVERNMENTAL GROUPS (Summary)

This proposed rule, which continues the provisions of the August 1, 2010 and the December 1, 2010 emergency rules, amends the provisions governing the Program for All Inclusive Care for the Elderly (PACE) to reduce the capitated amount paid to PACE organizations (approximately 2,840 service units). It is anticipated that implementation of this proposed rule will decrease program expenditures in the Medicaid Program by approximately $349,056 for FY 10-11, $502,193 for FY 11-12 and $517,259 for FY 12-13.

IV. ESTIMATED EFFECT ON COMPETITION AND EMPLOYMENT (Summary)

It is anticipated that the implementation of this proposed rule will not have an effect on competition. However, we anticipate that the implementation may have a negative effect on employment as it will reduce the payments made to PACE organizations. The reduction in payments may adversely impact the financial standing of these organizations and could possibly cause a reduction in employment opportunities.

Ambulatory Surgical Centers

The Department of Health and Hospitals, Bureau of Health Services Financing proposes to amend LAC 50:XI.7503 in the Medical Assistance Program as authorized by R.S. 36:254 and pursuant to Title XIX of the Social Security Act and as directed by Act 11 of the 2010 Regular Session of the Louisiana Legislature which states: “The secretary is directed to utilize various cost containment measures to ensure expenditures in the Medicaid Program do not exceed the level appropriated in this schedule, including but not limited to precertification, preadmission screening, diversion, fraud control, utilization review and management, prior authorization, service limitations, drug therapy management, disease management, cost sharing, and other measures as permitted under federal law.” This proposed Rule is promulgated in accordance with the provisions of the Administrative Procedure Act, R.S. 49:950 et seq.

As a result of a budgetary shortfall in state fiscal year 2010, the Department of Health and Hospitals, Bureau of Health Services Financing amended the provisions governing the reimbursement methodology for ambulatory surgical centers to further reduce the reimbursement rates paid for ambulatory surgical services (Louisiana Register, Volume 36, Number 10). As a result of a budgetary shortfall in state fiscal year 2011, the department promulgated an Emergency Rule which amended the provisions governing the reimbursement methodology for ambulatory surgical centers to reduce the reimbursement rates (Louisiana Register, Volume 36, Number 8). The department promulgated an Emergency Rule which amended the provisions of the August 1, 2010 Emergency Rule to revise the formatting of LAC 50:XI.7503 as a result of the promulgation of the October 20, 2010 final Rule governing ambulatory surgical centers (Louisiana Register, Volume 36, Number 11).

Due to a continuing budgetary shortfall in state fiscal year 2011, the department promulgated an Emergency Rule which amended the provisions governing the reimbursement methodology for ambulatory surgical centers to further reduce the reimbursement rates (Louisiana Register, Volume 36, Number 12). This proposed Rule is being promulgated to continue the provisions of the November 20, 2010 and the December 1, 2010 Emergency Rules.

A. - D. …

E. Effective for dates of service on or after August 1, 2010, the reimbursement for surgical services provided by an ambulatory surgical center shall be reduced by 4.4 percent of the fee amounts on file as of July 31, 2010.

F. Effective for dates of service on or after December 1, 2010, the reimbursement for surgical services provided by an ambulatory surgical center shall be reduced by 2 percent of the fee amounts on file as of November 30, 2010.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 35:1889 (September 2009), amended LR 36:2278 (October 2010), LR 37:

Implementation of the provisions of this Rule may be contingent upon the approval of the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), if it is determined that submission to CMS for review and approval is required.

Family Impact Statement

In compliance with Act 1183 of the 1999 Regular Session of the Louisiana Legislature, the impact of this proposed Rule on the family has been considered. It is anticipated that this proposed Rule may have an adverse impact on family functioning, stability and autonomy as described in R.S. 49:972 in the event that provider participation in the Medicaid Program is diminished as a result of reduced reimbursement rates.

Interested persons may submit written comments to Don Gregory, Bureau of Health Services Financing, P.O. Box 91030, Baton Rouge, LA 70821-9030. He is responsible for responding to inquiries regarding this proposed Rule.

A public hearing on this proposed Rule is scheduled for Wednesday, January 26, 2011 at 9:30 a.m. in Room 118, Bienville Building, 628 North Fourth Street, Baton Rouge, LA. At that time all interested persons will be afforded an opportunity to submit data, views or arguments either orally or in writing. The deadline for receipt of all written comments is 4:30 p.m. on the next business day following the public hearing.

Secretary

It is anticipated that the implementation of this proposed rule will result in estimated programmatic savings to the state of $56,899 for FY 10-11, $109,120 for FY 11-12 and $113,051 for FY 12-13. It is anticipated that $328 ($164 SGF and $164 FED) will be expended in FY 10-11 for the state’s administrative expense for promulgation of this proposed rule and the final rule. The numbers reflected above are based on a blended Federal Medical Assistance Percentage (FMAP) rate of 74.76 percent (in FY 10-11). The enhanced rate of 81.48 percent for the first six months of the fiscal year is authorized by the American Recovery and Reinvestment Act (ARRA) of 2009. To the extent that additional enhanced federal match would be available and appropriated after December 2010 (end of the ARRA eligibility), state general fund match could be reduced in the current fiscal year.

II. ESTIMATED EFFECT ON REVENUE COLLECTIONS OF STATE OR LOCAL GOVERNMENTAL UNITS (Summary)

It is anticipated that the implementation of this proposed rule will reduce federal revenue collections by approximately $168,854 for FY 10-11, $226,120 for FY 11-12 and $232,247 for FY 12-13. It is anticipated that $164 will be expended in FY 10-11 for the federal administrative expenses for promulgation of this proposed rule and the final rule. The numbers reflected above are based on a blended Federal Medical Assistance Percentage (FMAP) rate of 74.76 percent (in FY 10-11). The enhanced rate of 81.48 percent for the first six months of the fiscal year is authorized by the American Recovery and Reinvestment Act (ARRA) of 2009. To the extent that additional enhanced federal match would be available and appropriated after December 2010 (end of the ARRA eligibility), state general fund match could be reduced in the current fiscal year.

III. ESTIMATED COSTS AND/OR ECONOMIC BENEFITS TO DIRECTLY AFFECTED PERSONS OR NONGOVERNMENTAL GROUPS (Summary)

This proposed rule, which continues the provisions of the November 20, 2010 and the December 1, 2010 emergency rules, amends the provisions governing the reimbursement methodology for ambulatory surgical centers to further reduce the reimbursement rates for surgical services (approximately 28,500 services annually). It is anticipated that implementation

of this proposed rule will decrease program expenditures in the Medicaid Program by approximately $226,081 for FY 10-11, $335,240 for FY 11-12 and $345,298 for FY 12-13.

IV. ESTIMATED EFFECT ON COMPETITION AND EMPLOYMENT (Summary)

It is anticipated that the implementation of this proposed rule will not have an effect on competition. However, we anticipate that the implementation may have a negative effect on employment as it will reduce the payments made to ambulatory surgical centers. The reduction in payments may adversely impact the financial standing of ambulatory surgical centers and could possibly cause a reduction in employment opportunities.

Don Gregory	Robert E. Hosse
Medicaid Director	Staff Director
1012#117	Legislative Fiscal Office

NOTICE OF INTENT

Department of Health and Hospitals
Bureau of Health Services Financing

Early and Periodic Screening, Diagnosis and Treatment

The Department of Health and Hospitals, Bureau of Health Services Financing proposes to amend LAC 50: XV.6903 and §6905 in the Medical Assistance Program as authorized by R.S. 36:254 and pursuant to Title XIX of the Social Security Act and as directed by Act 11 of the 2010 Regular Session of the Louisiana Legislature which states: “The secretary is directed to utilize various cost containment measures to ensure expenditures in the Medicaid Program do not exceed the level appropriated in this schedule, including but not limited to precertification, preadmission screening, diversion, fraud control, utilization review and management, prior authorization, service limitations, drug therapy management, disease management, cost sharing, and other measures as permitted under federal law.” This proposed Rule is promulgated in accordance with the provisions of the Administrative Procedure Act, R.S. 49:950 et seq.

As a result of a budgetary shortfall in state fiscal year 2010, the Department of Health and Hospitals, Bureau of Health Services Financing amended the provisions governing the reimbursement methodology for dental services in the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program to reduce the reimbursement fees (Louisiana Register, Volume 36, Number 9).

As a result of a budgetary shortfall in state fiscal year 2011, the department promulgated an Emergency Rule which amended the provisions governing the reimbursement methodology for EPSDT dental services to further reduce the reimbursement rates. In addition, this emergency rule also amended the provisions governing the covered services and reimbursement methodology for the EPSDT Dental Program to include an additional dental procedure (Louisiana Register, Volume 36, Number 8). The department promulgated an Emergency Rule which amended the provisions of the August 1, 2010 Emergency Rule to revise the formatting of LAC 50:XV.6905 as a result of the promulgation of the September 20, 2010 final Rule governing EPSDT dental services (Louisiana Register, Volume 36, Number 11).

Due to a continuing budgetary shortfall, the department promulgated an Emergency Rule which amended the provisions governing the reimbursement methodology for EPSDT dental services to further reduce the reimbursement rates (Louisiana Register, Volume 36, Number 12). This proposed Rule is being promulgated to continue the provisions of the November 20, 2010 and the December 1, 2010 Emergency Rules.

Title 50

PUBLIC HEALTH─MEDICAL ASSISTANCE