Free ForwardHealth Request for Discretionary Waiver of Qualifications for Aregistered Nurse Supervisor, F-1142 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1142 (02/09)

STATE OF WISCONSIN

FORWARDHEALTH

REQUEST FOR DISCRETIONARY WAIVER OF QUALIFICATIONS FOR A REGISTERED NURSE SUPERVISOR
ForwardHealth requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. The information on this form is only to be used for the purpose of waiving qualifications for registered nurses (RNs) performing personal care worker (PCW) supervision duties while being mentored. The use of this form is voluntary and providers may develop their own form as long as it includes all the information on this form. Registered Nurse Supervisor Qualifications The provision of DHS 105.17(2)(a), Wis. Admin. Code, states that an RN supervisor under contract with or employed by a personal care provider shall have all of the following qualifications: 1 Be licensed in Wisconsin pursuant to s. 441.06, Wis. Stats. Be a public health nurse or be currently or previously employed by a home health agency, an independent living center, or a hospital rehabilitation unit. Provide documentation of experience in providing personal care services in the home. Registered Nurse Supervisor Duties The provision of DHS 105.17(2)(b), Wis. Admin. Code, states that an RN supervisor shall perform all of the following duties: Evaluate the need for service and make referrals to other services as appropriate. Secure written orders from the member's physician. These orders are to be renewed once every three months unless the physician specifies that orders covering a period of time up to one year are appropriate, or when the member's needs change, whichever occurs first. Develop a plan of care for the member, giving full consideration to the member's preferences for service arrangements and choice of PCWs, interpret the plan to the PCW, include a copy of the plan in the member's health record, and review the plan at least every 60 days and update it as necessary. Develop appropriate time and service reporting mechanisms for PCWs and instruct the workers on their use. Give the PCW written instructions about the services to be performed and demonstrate to the PCW how to perform the services. Evaluate the competency of the PCW to perform the services.

INSTRUCTIONS A personal care provider contracting with or employing an RN supervisor of PCWs who does not meet the qualifications stated in DHS 105.17(2), Wis. Admin. Code, and requests a waiver of these qualifications is required to submit the information contained in this form to ForwardHealth. Providers are required to include all information requested on this form. If necessary, attach additional pages if more space is needed. Provide enough information for ForwardHealth to make a reasonable judgment. The applicant's resume must be included with this form. Providers may submit this form by fax to ForwardHealth at (608) 266-1096, to the attention of the Personal Care Analyst. Providers who wish to submit this form by mail may do so by submitting it to the following address: Personal Care Analyst Wisconsin Medicaid and BadgerCare Plus Department of Health Services 1 W Wilson PO Box 309 Madison WI 53701-0309
1

Wisconsin Medicaid will not waive this qualification of DHS 105.17(2), Wis. Admin. Code, for any applicant.

REQUEST FOR DISCRETIONARY WAIVER OF QUALIFICATIONS FOR A REGISTERED NURSE SUPERVISOR F-1142 (02/09)

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SECTION I -- REGISTERED NURSE SUPERVISOR APPLICANT AGENCY INFORMATION Name -- Agency

National Provider Identifier -- Agency

Address (Street, City, State, and ZIP Code) -- Agency Telephone Number -- Agency

The agency listed above requests an DHS 106.13, Wis. Admin. Code, Discretionary Waiver of provision DHS 105.17(2)(a)2 or 3, Wis. Admin. Code, for _______________________________________ for the following reasons listed and therefore strict
(Name -- RN Supervisor Applicant)

enforcement of a requirement would result in unreasonable hardship on the provider or on a member (e.g., shortage of experienced home care nurses in vicinity).

Summarize the specific qualifications and experience of the RN Supervisor Applicant. In addition, the applicant's resume must be attached.

SECTION II -- REGISTERED NURSE SUPERVISOR MENTOR An RN Supervisor who meets DHS 105.17(2), Wis. Admin. Code, requirements will mentor the RN Supervisor Applicant for a period of six months. The RN Supervisor listed below will be mentoring the RN Supervisor Applicant during this period. Name -- RN Supervisor Mentor Title -- RN Supervisor Mentor

Address -- RN Supervisor Mentor (Street, City, State, and ZIP Code -- only if different from Agency address)

Telephone Number -- RN Supervisor Mentor (only if different from Agency telephone)

I assure that
(Name -- RN Supervisor Applicant)

will:



Be mentored by an RN who meets DHS 105.07(2), Wis. Admin. Code, requirements for an RN supervisor of PCWs. Have ready access to the assigned RN supervisor mentor. Be mentored for six months. Be familiarized with the PCW training program, which will be documented in the assigned RN supervisor mentor's records.

I assure that the health, safety, or welfare of any member will not be adversely affected as a result of the Department of Health Services granting this waiver. SIGNATURE -- Authorized Representative of Personal Care Agency Title Date Signed

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