Extended Personal Care Service (EPCS) Provider Training Procedure Agreement, SFN 576 525-05-60-57

(NEW 07/01/2024 ML #3847)

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Nurse Educator will complete the SFN 576 if medical tasks will be provided by a non-nurse QSP who has been trained and verified to be competent at time of training.

1. Nurse Educator will fill out member name, member Medicaid ID number, nurse educator name and phone number, back up nurse educator name and phone number, and case manager name and phone number

2. Nurse Educator will fill review critical incident reporting requirements with non-nurse QSPs completing the medical tasks

3. Procedure and Training

   1. Nurse Educator will fill check boxes after completing training tasks including: reason for task and risk of task, observation of client response, possible side effects to client and response, proper procedure, nurse demonstration, return demonstration and procedural guidance provided

   2. Nurse Educator will fill include detailed instructions and steps for nursing tasks including:

      1. Contraindications

      2. Risks

      3. Precautions

      4. Reportable incidents

      5. Contingency Plan in case of emergency

   3. Each trained non-nurse QSP verifies agreement and compliance with the information listed on the SFN 576.

      1. Non-nurse QSP prints name, signs, and dates

      2. Nurse educator signs name and date

4. Nurse Educator will submit document to HCBS Case Manager for State Program Administrator review.