Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11259 (10/08)

STATE OF WISCONSIN

WISCONSIN MEDICAID

DECLARATION OF SKILL ACQUISITION -- PRIVATE DUTY NURSING FOR MEMBERS VENTILATOR DEPENDENT FOR LIFE-SUPPORT PEDIATRIC (AGE 0-16)
Wisconsin Medicaid requires information to enable Medicaid to certify providers and to authorize and pay for medical services provided to eligible members. Personally identifiable information about providers or other entities is used for purposes directly related to program administration such as determining the certification of providers or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of payment for services. The use of this form is mandatory. INSTRUCTIONS: Print or type clearly. SECTION I -- PROVIDER INFORMATION Name -- Provider (Last Name, First Name, Middle Initial)

Maiden Name (If Applicable)

Provider ID (New Applicants May Skip)

Check all applicable boxes. Licensed as a registered nurse pursuant to s. 441.06, Wis. Stats. Licensed as a practical nurse pursuant to s. 441.10, Wis. Stats. The following items are the minimum skills and knowledge requirements the provider is required to meet to be certified pursuant to s. HFS 105.19(1)(b), Wis. Admin. Code, (certification) to provide private duty nursing services described under s. HFS 107.113, Wis. Admin. Code, (covered services) to Medicaid members dependent on a ventilator for life-support. A response of "Yes" for all 15 procedures is a minimum requirement for certification. The date(s) should be the most recent date(s) the skills for pediatrics were updated and successfully demonstrated. Approved facilities are Joint Commission-accredited hospitals and nursing homes state approved for ventilator care. Within the past two years has the provider been recognized by an approved facility as having successfully demonstrated the respiratory care skills that are listed in Elements 1-14 of this form? Yes No Date of Successful Completion of Skills Demonstration If No, explain.

Continued

DECLARATION OF SKILL ACQUISITION -- PRIVATE DUTY NURSING FOR MEMBERS VENTILATOR DEPENDENT FOR LIFE-SUPPORT PEDIATRIC F-11259 (10/08)

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SECTION II -- RESPIRATORY CARE SKILLS 1. 2. Airway management, including tracheostomy care, changing of a tracheostomy tube, and procedures in the event of accidental extubation or mucous plug. Tracheal suctioning techniques consistent with pulmonary hygiene techniques: Use of normal saline lavage. Knowledge of manual ventilation during trach suctioning or changes. 3. 4. 5. 6. 7. 8. 9. Airway humidification. Oxygen therapy, including operation of oxygen systems and auxiliary oxygen delivery devices. Respiratory assessment, including monitoring of breath sounds, patient color, chest excursion, secretions, and vital signs. Ventilator management: operation of positive pressure ventilator by means of a tracheostomy, including, but not limited to, different modes of ventilation, types of alarms and responding to alarms, troubleshooting ventilator dysfunction. Knowledge of weaning a patient from the ventilator. Chest physiotherapy. Medication administration, including administration of aerosolized medications and assessment of their actions and effects.

10. Documentation of service: Content: Chapter N 6.03, Wis. Admin. Code, standards of practice/nursing process -- developing a narrative. Sample flow sheets. 11. Operation and assembly of ventilator circuit (delivery system). 12. Proper cleaning and disinfection of equipment. 13. Operation of a manual resuscitator. 14. Emergency assessment and management. Does the provider possess from an approved facility listed in Element 15 a cardiopulmonary resuscitation skills (CPR) card that documents within the past two years that the provider has successfully completed a CPR course for the professional rescuer? Yes No

If "No," explain.

15. A CPR card (most recent recognition of successful completion) from the American Red Cross or American Heart Association. Continued

DECLARATION OF SKILL ACQUISITION -- PRIVATE DUTY NURSING FOR MEMBERS VENTILATOR DEPENDENT FOR LIFE-SUPPORT PEDIATRIC F-11259 (10/08)

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SECTION II -- RESPIRATORY CARE SKILLS (Continued) Indicate where the provider received his or her training for Element 15. Name -- Facility Name -- Instructor

Instructor ID Number

Telephone Number -- Contact Person

Address (Street, City, State, ZIP+4 Code)

SECTION III -- CARD INFORMATION Name -- Candidate

Issue Date

Renewal / Expiration Date

A copy of the institution's dated curriculum, checklist, syllabus, or certificate that verifies you successfully completed demonstrated competence in all of the ventilator care skills on pages 2 and 3 for pediatric care must be available upon request from Wisconsin Medicaid. If none of these documents are available, a letter from the approved institution (not an individual) will be acceptable. The letter must state the following: the date(s) of demonstration, that the demonstration was for pediatric care, and that you demonstrated competence in all of the ventilator care skills for pediatric patients listed in Elements 1-14. The letter must be available upon request by Wisconsin Medicaid.

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